Nokea
Which of the following nursing activities is an example of evaluation?
- A. Checking a client’s blood pressure 30 minutes after administering an antihypertensive medication
- B. Administering prescribed oxygen therapy to a client
- C. Developing a plan of care for a new client
- D. Teaching a client about low-sodium dietary options
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
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Mr. RR is being prepared for surgery. Nursing care would include:
- A. Careful assessment of neurologic signs to establish baseline data for post-operative care
- B. Planning activities for Mr. RR
- C. Administration of an SS enema to prevent post-operative impaction
- D. Explaining to Mr. RR post-operative complications
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Assessment of neurologic signs establishes baseline for post-op care.
2. Helps detect any changes post-surgery.
3. Enables prompt intervention if any issues arise.
4. Planning activities (B) is not a priority pre-surgery.
5. Enema (C) may not be necessary for all surgeries.
6. Explaining complications (D) is important but not a primary pre-op nursing care.
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: The correct answer is D, Arcus senilis. This condition does not cause visual problems in the older adult. Arcus senilis is a grayish-white ring around the cornea, which does not affect vision. Glaucoma, macular degeneration, and cataracts are conditions that can lead to visual impairment in older adults. Glaucoma is characterized by increased pressure in the eye, which can damage the optic nerve and lead to vision loss. Macular degeneration affects the central part of the retina, leading to blurred or distorted vision. Cataracts cause clouding of the lens, resulting in decreased vision. Therefore, Arcus senilis is the correct choice as it does not cause visual problems compared to the other conditions listed.
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
- A. Conductive
- B. Mixed
- C. Sensorineural
- D. Central
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. Hearing aids are most effective for sensorineural hearing loss as they amplify sound signals to compensate for damage to the inner ear hair cells or auditory nerve. This type of hearing loss is due to problems in the inner ear or auditory nerve, which can be partially compensated for by using hearing aids. The other choices, A: Conductive, B: Mixed, and D: Central, are not as effectively improved by hearing aids. Conductive hearing loss is usually due to problems in the outer or middle ear, which can often be treated with medical or surgical interventions. Mixed hearing loss involves a combination of conductive and sensorineural components, and may require a combination of interventions. Central hearing loss is due to problems in the central auditory pathways in the brain, and is not typically improved by hearing aids.
Which of the ff is the main reason why older clients with AIDS need more care than their younger counterparts?
- A. Because the older clients lack balanced diet and activity
- B. Because older clients lack knowledge about disorders
- C. Because older clients have a faster progression of disease
- D. Because older clients do not generally adhere to a therapy
Correct Answer: C
Rationale: The correct answer is C because older clients with AIDS have a faster progression of the disease due to age-related changes in the immune system, making them more vulnerable to complications. This results in a greater need for care compared to younger counterparts. Choice A is incorrect as lack of balanced diet and activity does not directly relate to the progression of AIDS. Choice B is incorrect as knowledge about disorders is not the main factor affecting the level of care needed. Choice D is incorrect as adherence to therapy is important but not the main reason older clients need more care.
Which of the ff should a client with auto immune disorder be advised to avoid?
- A. Resting during the periods of severe exacerbation
- B. Regular exercise during the periods of remission
- C. Being in crowds during the periods of immunosuppression
- D. Humid environment during the periods of remission
Correct Answer: C
Rationale: The correct answer is C: Being in crowds during the periods of immunosuppression. Clients with autoimmune disorders have compromised immune systems, making them more susceptible to infections. Being in crowds increases the risk of exposure to various pathogens, potentially leading to infections. Avoiding crowds during periods of immunosuppression helps minimize the risk of infections.
A: Resting during the periods of severe exacerbation is important for managing symptoms and conserving energy, but it is not specifically related to avoiding triggers for autoimmune disorders.
B: Regular exercise during the periods of remission is beneficial for overall health and can help manage autoimmune disorders, as long as it is appropriate and not excessive.
D: Humid environments during the periods of remission do not directly impact autoimmune disorders unless the individual has a specific sensitivity to humidity.