Nokea
Which of the following is more life threatening?
- A. BP=180/100
- B. BP=160/120
- C. BP=90/60
- D. BP=80/50
Correct Answer: D
Rationale: BP 80/50 is most life-threatening e.g., hypoperfusion risks failure vs. 180/100 (hypertension), 160/120 (severe), 90/60 (borderline). Nurses prioritize this e.g., fluids for stability, per hemodynamics.
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Rommel told Budek, 'Do you think Im crazy?' Budek responded, 'Do you think your crazy?' Budek uses what example of therapeutic communication?
- A. Reflecting
- B. Restating
- C. Exploring
- D. Seeking clarification
Correct Answer: A
Rationale: Budek's 'Do you think you're crazy?' is reflecting (A), redirecting Rommel's question to explore his feelings or self-perception. Restating (B) repeats verbatim (e.g., 'You think you're crazy?'). Exploring (C) digs deeper (e.g., 'Why do you ask?'). Clarification (D) seeks meaning. Reflecting, per Peplau, fosters self-reflection, apt for Rommel's doubt, making A correct.
When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part?
- A. Quickly explain the surgery procedures and the risks to the client.
- B. Cancel the surgery.
- C. Ask your supervising RN to explain the surgery procedure and its risks.
- D. Notify the physician.
Correct Answer: D
Rationale: When a client scheduled for surgery shows a lack of understanding and expresses concern, notifying the physician is the best action for a licensed vocational nurse. The physician, as the primary decision-maker and the one obtaining informed consent, has the responsibility to ensure the client fully comprehends the procedure, risks, and benefits. The nurse's role is to facilitate communication and advocate for the client's needs, not to independently explain complex medical details outside their scope or cancel the surgery, which exceeds their authority. Asking the supervising RN might help, but it delays direct resolution by the physician, who is legally accountable for ensuring consent is informed. This approach upholds the nurse's duty to prioritize client understanding and safety while respecting professional boundaries and legal standards.
Type of recording that integrates all data about the problem, gathered by members of the health team.
- A. POMR
- B. Traditional
- C. Resource oriented
- D. Source oriented
Correct Answer: A
Rationale: POMR (Problem-Oriented Medical Record) (A) integrates team data per problem, per Weed's system. Traditional (B) and source-oriented (D) separate by discipline. Resource-oriented (C) isn't recognized. A fits interdisciplinary focus, making it correct.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth
- B. The medication will be needed throughout the child's lifetime
- C. The medication schedule can be arranged to allow for drug holidays
- D. The medication is given one time daily every other day
Correct Answer: B
Rationale: Lifetime thyroid hormone replacement is needed for congenital hypothyroidism to prevent developmental delays growth spurts, holidays, or alternate days don't suffice. Nurses reinforce this, ensuring adherence, critical for normal growth in this endocrine disorder.
All of the following can cause tachycardia except:
- A. Fever
- B. Exercise
- C. Sympathetic nervous system stimulation
- D. Parasympathetic nervous system stimulation
Correct Answer: D
Rationale: Parasympathetic stimulation slows heart rate; others increase it.