Nokea
Which of the following is not a criterion for a valid informed consent that a nurse should identify?
- A. freely given
- B. with coercion
- C. has an explanation of procedures
- D. describes the alternatives
Correct Answer: B
Rationale: The correct answer is B: with coercion. Informed consent must be freely given without any form of coercion to ensure the individual's autonomy and decision-making capacity. Coercion can lead to involuntary consent, undermining the principle of respect for autonomy. Choices A, C, and D are all criteria for valid informed consent. Choice A ensures the individual is voluntarily agreeing without any external pressure. Choice C ensures the individual understands the procedures involved, promoting transparency. Choice D ensures the individual is aware of alternative options, allowing for an informed decision-making process.
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A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?
- A. Independent intervention
- B. Dependent intervention
- C. Interdependent intervention
- D. Collaborative intervention
Correct Answer: C
Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client.
Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
- A. Rise in blood pressure and heart rate
- B. Rise in blood pressure and drop in heart rate
- C. Drop in blood pressure and rise in heart rate
- D. none of the above
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client’s nursing care plan? Choose all that apply
- A. Administer prescribed nephrotoxic drugs
- B. Encourage ambulation and liberal fluid
- C. Observe aseptic principles when changing intake
- D. Provide a comfortable position
Correct Answer: B
Rationale: The correct answer is B: Encourage ambulation and liberal fluid. Encouraging ambulation can help in the movement of kidney stones and alleviate pain. Liberal fluid intake helps in flushing out kidney stones and preventing further stone formation.
Incorrect options:
A: Administering prescribed nephrotoxic drugs can worsen kidney function and exacerbate the pain.
C: Observing aseptic principles when changing intake is important for infection prevention but not directly related to pain management for renal calculi.
D: Providing a comfortable position can offer temporary relief but does not address the underlying cause of kidney stone pain.
When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
- A. When the client’s color does not improve
- B. When the client level of consciousness decreases
- C. When the client is in a state of respiratory arrest
- D. When the client cannot effectively use the diaphragm
Correct Answer: C
Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.
A 19 y.o. student develops trigeminal neuralgia. Which of the ff. actions will most likely aggravate her pain?
- A. Sleeping
- B. Reading
- C. Eating
- D. Cooking
Correct Answer: C
Rationale: The correct answer is C: Eating. Chewing food can trigger trigeminal nerve pain due to the movement and pressure applied on the nerve. The other choices (A: Sleeping, B: Reading, D: Cooking) do not involve the same level of jaw movement and pressure on the trigeminal nerve, thus are less likely to aggravate the pain. Therefore, eating is the most likely action to worsen trigeminal neuralgia symptoms in this scenario.