Nokea
Which of the following statement best describe patient advocacy?
- A. Ignoring patient needs
- B. Supporting patient rights
- C. A routine task
- D. A medical treatment
Correct Answer: B
Rationale: Patient advocacy is supporting patient rights (B), per nursing e.g., voicing wishes. Not ignoring (A), not routine (C), not treatment (D) rights-focused. B best defines advocacy's protective role, making it correct.
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A client with a new diagnosis of cirrhosis is receiving dietary management education from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of sodium-rich foods.
- B. You should decrease your intake of sodium-rich foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of dairy products.
Correct Answer: B
Rationale: Reducing the intake of sodium-rich foods is beneficial for managing fluid retention and symptoms of cirrhosis. Excessive sodium can lead to fluid buildup in the body, worsening edema and ascites commonly associated with cirrhosis. Therefore, advising the client to decrease their intake of sodium-rich foods is crucial in the dietary management of cirrhosis. Option A is incorrect as increasing sodium intake would exacerbate fluid retention. Option C is irrelevant to cirrhosis management unless the client has lactose intolerance. Option D is incorrect as increasing dairy product intake may not be suitable for all patients with cirrhosis, especially if they have complications like hepatic encephalopathy.
The nurse is suctioning a client through a tracheal tube. During the procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?
- A. Notify the registered nurse immediately.
- B. Stop the procedure and oxygenate the client.
- C. Continue to suction the client at a quicker pace.
- D. Ensure that the suction is limited to 15 seconds.
Correct Answer: B
Rationale: A 10-beat heart rate drop during suctioning suggests vagal stimulation or hypoxia; stopping the procedure and oxygenating (B) is the next action to reverse this. Notifying the RN (A) or limiting time (D) follows. Continuing (C) risks worsening. B is correct. Rationale: Suctioning can trigger bradycardia via vagal nerve activation or oxygen depletion; halting and oxygenating restores stability, a critical step per airway management guidelines, preventing further cardiac compromise.
Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
- A. clinical judgment of transition to a higher level of wellness
- B. nursing judgment that in some area no pathology exists
- C. a judgment that in some area there is more wellness than illness
- D. statement of an area of family strength to use in interventions
Correct Answer: A
Rationale: A wellness nursing diagnosis best describes a clinical judgment of transitioning to a higher wellness level, focusing on enhancing health beyond mere absence of disease. Unlike pathology-based diagnoses, it identifies potential for growth like improving nutrition in a healthy client reflecting nursing's preventive role. Judging no pathology or more wellness than illness is narrower, missing the forward-looking aspect, while family strengths support interventions but aren't the diagnosis. This perspective encourages proactive care, aligning with wellness models to elevate client health.
It is best described as a systematic, rational method of planning and providing nursing care for individuals, families, group and community
- A. Assessment
- B. Nursing Process
- C. Diagnosis
- D. Implementation
Correct Answer: B
Rationale: The nursing process (B) is a comprehensive, systematic framework used by nurses to deliver patient-centered care. It encompasses five steps: assessment (data collection), diagnosis (identifying health problems), planning (setting goals and interventions), implementation (carrying out the plan), and evaluation (assessing outcomes). This definition matches the description in the question as a rational, organized method applicable to individuals, families, groups, and communities. Assessment (A) is only the first step, not the entire method. Diagnosis (C) is a single phase focused on problem identification, while implementation (D) is the action phase, neither encompassing the full scope described. The nursing process integrates critical thinking and evidence-based practice to ensure holistic care, making B the accurate answer reflecting its broad, systematic nature.
A client receives education on dietary management for ulcerative colitis from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of high-fiber foods.
- B. You should avoid foods containing lactose.
- C. You should decrease your intake of dairy products.
- D. You should increase your intake of dairy products.
Correct Answer: C
Rationale: The correct statement the nurse should include in the teaching is to decrease the intake of dairy products. This is because reducing the intake of dairy products is beneficial in managing symptoms of ulcerative colitis. Dairy products can aggravate symptoms due to their lactose content, thus advising the client to decrease their consumption can help alleviate discomfort and promote better management of the condition.\nChoice A is incorrect because increasing high-fiber foods may worsen symptoms in some individuals with ulcerative colitis.\nChoice B is incorrect as while it is advised to avoid foods containing lactose, this alone does not encompass the full dietary management for ulcerative colitis.\nChoice D is incorrect as increasing the intake of dairy products can exacerbate symptoms in individuals with ulcerative colitis due to their lactose content.