Nokea
Which of the following is true about the NURSING CARE PLAN?
- A. It is nursing centered
- B. Rationales are supported by interventions
- C. Verbal
- D. Atleast 2 goals are needed for every nursing diagnosis
Correct Answer: A
Rationale: The nursing care plan is nursing-centered (A), focusing on nurse-led actions, per planning standards. Rationales support interventions (B) reverses logic, verbal (C) isn't typical, two goals (D) isn't required. A aligns with purpose, making it correct.
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The nurse recorded Mr. Gary's vitals in his chart. This is an example of?
- A. Documentation
- B. Standard precautions
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.
Becky has been NPO since midnight in preparation for a blood test. The adreno-cortical response is activated. Which of the following is an expected response?
- A. Low blood pressure
- B. Warm, dry skin
- C. Decreased serum sodium levels
- D. Decreased urine output
Correct Answer: D
Rationale: The adrenocortical response, triggered by fasting (NPO status), activates stress hormones like cortisol and aldosterone, conserving resources during deprivation. Decreased urine output results from aldosterone's promotion of sodium and water reabsorption in the kidneys, maintaining fluid volume and blood pressure. This adaptation counters the stress of fasting, ensuring homeostasis. Low blood pressure would oppose this, as the response aims to stabilize circulation, not reduce it. Warm, dry skin isn't typical; stress might cause cool, clammy skin from vasoconstriction, but fasting alone doesn't dictate this. Decreased serum sodium levels contradict aldosterone's sodium-retaining effect, which elevates or stabilizes sodium. Decreased urine output aligns with the body's conservation mechanism, making it the expected physiological response in this scenario, critical for nurses to recognize during patient monitoring.
Which of the following cannot be corrected by dialysis:
- A. Elevated creatinine
- B. Hyperkalemia
- C. Anaemia
- D. Hypernatremia
Correct Answer: C
Rationale: Dialysis corrects biochemical imbalances in renal failure. Elevated creatinine (choice A) is cleared, reducing toxicity. Hyperkalemia (choice B) is adjusted by potassium removal. Anemia (choice C) persists, as dialysis doesn't replace erythropoietin or red cells, requiring separate treatment. Hypernatremia (choice D) is managed by fluid/sodium balance. C is correct, dialysis limitation. Nurses monitor hemoglobin, administer erythropoietin, and coordinate care, addressing anemia beyond dialysis.
As a nurse manager, which of the following best describes this function?
- A. Initiate modification on client's lifestyle
- B. Protect client's right
- C. Coordinates the activities of other members of the health team in managing patient care
- D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution
Correct Answer: D
Rationale: A nurse manager's role encompasses planning (vision formulation), organizing (team coordination), directing (training), and controlling (audits), per management theories like Venzon's. This holistic function e.g., setting care standards, training staff, evaluating outcomes ensures quality across a unit, unlike narrower roles like lifestyle change (change agent), rights protection (advocate), or team coordination (case manager). It's a strategic position driving institutional excellence, pivotal in healthcare leadership.
The nurse cares for 4 clients. Which activity demonstrates the nurse's understanding of how ethnicity influences the client's health?
- A. Provide financial resources from local organizations to pay for a client's health care needs.
- B. Teach a client using drawings, repetition, short sentences, and simple language.
- C. Assess a 5-month-old African American client for sickle cell anemia.
- D. Explain the consequences of not exercising and only eating fast food due to a stressful job.
Correct Answer: C
Rationale: Ethnicity influences health through genetic predispositions and cultural factors. Assessing a 5-month-old African American client for sickle cell anemia (C) reflects this, as the disease is prevalent in African descent populations due to a genetic mutation. Providing financial resources (A) addresses access, not ethnicity-specific health. Teaching with simple methods (B) aids comprehension but isn't ethnicity-tied. Diet and exercise advice (D) is general, not ethnic-specific. C is correct. Rationale: Sickle cell anemia's higher incidence in African Americans requires early screening to prevent complications like vaso-occlusive crises, showcasing culturally competent care rooted in genetic epidemiology, unlike the other options.