Nokea
Which of the following is TRUE with regards to Client Goals?
- A. They are specific, measurable, attainable and time bounded
- B. They are general and broadly stated
- C. They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.
- D. Example is : After discharge planning, Client demonstrated the proper psychomotor skills for insulin injection.
Correct Answer: A
Rationale: Client goals are specific, measurable, attainable, time-bound (A), per SMART criteria. General (B) lacks focus, C details criteria not truth, D is an example, not definition. A defines goal-setting, making it correct.
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The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways?
- A. The blood pressure will be elevated.
- B. The pulse will be low.
- C. Temperature will be elevated.
- D. Blood pressure will be low.
Correct Answer: A
Rationale: A 70% hematocrit, abnormally high, increases blood viscosity, elevating blood pressure, not lowering pulse or raising temperature. Nurses monitor this for circulatory strain.
Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
- A. High
- B. Low
- C. At the low end of the normal range
- D. At the high end of the normal range
Correct Answer: D
Rationale: Tympanic temp of 37.9°C falls within normal (36.6-38°C) e.g., slightly elevated from barking cough stress. It's not high (>38°C), low (<36.6°C), or low-end. Nurses interpret this as high-normal, monitoring for trends in acute respiratory cases, per standard ranges.
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
- A. Elbow restraints
- B. Full arm restraints
- C. Wrist restraints
- D. Mummy restraints
Correct Answer: A
Rationale: Elbow restraints are used post-cleft palate repair to prevent an 18-month-old from touching the surgical site, protecting sutures without overly restricting movement. Full arm or wrist restraints are excessive, while mummy restraints are impractical and unnecessary. Nurses apply these to balance safety and comfort, educating parents on their temporary use to ensure healing, critical for speech and feeding outcomes.
Which of the following statement is TRUE about illness behavior?
- A. How people react when they are sick
- B. How people prevent illness
- C. How people treat illness
- D. All of the above
Correct Answer: A
Rationale: Illness behavior is how people react when sick (A), per sociology e.g., seeking care. Prevention (B) and treatment (C) are separate, not all (D). A truly defines illness response, making it correct.
Critical thinking is an active organized cognitive process used to carefully examine one's thinking. It allows the nurse to
- A. Direct the assessment in a meaningful and purposeful way
- B. Review assessment with other health care providers
- C. Determination of the nursing care delivered
- D. Indentifies anticipated client responses to illness
Correct Answer: A
Rationale: Critical thinking directs assessment purposefully e.g., probing fatigue to link it to anemia ensuring data collection is focused and relevant. This active process analyzes, synthesizes, and prioritizes, enhancing care planning. Reviewing with providers follows assessment, not its direction. Determining care is planning/implementation, not assessment's role. Identifying responses fits evaluation, not initial data-gathering. Critical thinking's role in steering assessment ensures efficiency and depth, making it the key way nurses apply this cognitive skill in practice.