Nokea
The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?
- A. Uneven shoulder and pelvic heights
- B. Symmetrical scapulae
- C. Equal leg lengths
- D. Straight spinal alignment
Correct Answer: A
Rationale: The correct answer is A. Uneven shoulder and pelvic heights are indicative of scoliosis due to the lateral curvature of the spine. Symmetrical scapulae, equal leg lengths, and straight spinal alignment are not typical signs of scoliosis. Symmetrical scapulae and equal leg lengths suggest normal alignment, while straight spinal alignment does not reflect the characteristic curvature seen in scoliosis cases. Therefore, identifying uneven shoulder and pelvic heights is crucial in recognizing scoliosis.
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Which of the following actions should the nurse plan to take?
- A. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
- B. Prime the transfusion tubing with lactated Ringer's solution.
- C. Administer the transfusion through a 24-gauge IV catheter.
- D. Infuse the blood over a maximum of 6 hours.
Correct Answer: A
Rationale: The correct answer is A. Using a solution of 0.9% sodium chloride to flush the transfusion tubing is essential to ensure compatibility and prevent potential reactions between the blood product and other solutions. This is a standard practice to maintain the integrity of the blood product and prevent contamination. Flushing with lactated Ringer's solution (B) would introduce a different electrolyte composition that may affect the blood product. Administering the transfusion through a 24-gauge IV catheter (C) may not be appropriate for blood transfusions due to the risk of hemolysis or clotting. Infusing the blood over a maximum of 6 hours (D) is a general guideline for blood transfusions but is not the immediate action the nurse should plan to take.
Which of the following actions should the nurse include in the plan of care?
- A. Encourage physical activity prior to bedtime
- B. Replace the carpet with hardwood floors
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the top of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.
Which task should the nurse perform to practice distributive justice?
- A. Ensuring that a client who is homeless receives preventative medical care
- B. Allocating community resources fairly among all clients in need.
- C. Prioritizing care for clients based on medical necessity rather than financial status.
- D. Advocating for equal access to healthcare services for underserved populations.
- E. Developing programs that address social determinants of health to reduce disparities.
Correct Answer: E
Rationale: The correct answer is E because developing programs that address social determinants of health to reduce disparities aligns with the principle of distributive justice, which focuses on fair distribution of resources to reduce inequalities. By addressing social determinants of health, such as income inequality or access to education, the nurse is working towards creating equal opportunities for all individuals to achieve good health outcomes.
Choices A, B, C, and D do not directly address the root causes of health disparities and inequality. Option A focuses on providing care to a specific individual rather than addressing systemic issues. Option B talks about allocating resources fairly but lacks the focus on addressing social determinants. Option C mentions prioritizing care based on medical necessity, which may not necessarily target disparities. Option D discusses advocating for equal access, but it does not specifically address the underlying social determinants that contribute to inequalities.
A nurse is assessing a client who has historic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. self-centered behavior
- D. violates others rights
Correct Answer: C
Rationale: The correct answer is C: self-centered behavior. Individuals with historic personality disorder often display self-centered behavior as they prioritize their own needs and desires above others. This is due to their excessive need for admiration and attention. The other options are incorrect because: A: Suspicious of others is more characteristic of paranoid personality disorder. B: Callousness is more indicative of antisocial personality disorder. D: Violates others' rights is a feature of antisocial personality disorder as well.
A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.