Nokea
Which of the following statement is NOT true about crisis intervention?
- A. Aims to restore pre-crisis state
- B. Short term
- C. Requires long term therapy
- D. Focuses on immediate needs
Correct Answer: C
Rationale: Crisis intervention restores pre-crisis (A), is short-term (B), immediate-focused (D) 'requires long-term therapy' (C) isn't true, as it's brief, per Caplan. C's duration contradicts, making it untrue.
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What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Monitoring I&O ensures fluid balance with hyperosmotic enteral feeding.
These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals.
- A. Dependent
- B. Independent
- C. Interdependent
- D. Intradependent
Correct Answer: C
Rationale: Interdependent interventions involve collaboration across health disciplines e.g., a nurse and dietician planning a high-protein diet for nephrotic syndrome. Unlike dependent (physician-ordered), independent (nurse-initiated), or intradependent (non-existent), these require shared expertise, ensuring comprehensive care. This teamwork, common in complex cases, leverages diverse skills for optimal outcomes, a staple in multidisciplinary healthcare settings.
A client with pneumonia exhibits signs of respiratory distress and decreased oxygen saturation. What is the primary indication for initiating oxygen therapy in this client?
- A. Promoting lung expansion
- B. Enhancing antimicrobial therapy
- C. Improving oxygen delivery to tissues
- D. Reducing the risk of bacterial resistance
Correct Answer: C
Rationale: Improving oxygen delivery to tissues (C) is the primary indication for oxygen therapy in pneumonia with distress and low SpO2, correcting hypoxia from impaired gas exchange. Lung expansion (A) is secondary. Antimicrobial therapy (B) treats infection, not oxygenation. Bacterial resistance (D) is unrelated. Enhanced oxygen delivery supports vital organs, per infectious disease care principles, critical in acute respiratory compromise.
Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is a human being. What major ingredient of a therapeutic communication is Nurse Aida using?
- A. Empathy
- B. Positive regard
- C. Comfortable sense of self
- D. Self awareness
Correct Answer: B
Rationale: Nurse Aida uses positive regard (B), valuing Roger as a human despite his behavior, a key therapeutic communication ingredient per Rogers. Empathy (A) involves feeling with the client, not just valuing them. Comfortable sense of self (C) is the nurse's confidence, and self-awareness (D) is understanding one's reactions. Positive regard fosters acceptance, crucial for trust and healing, aligning with Aida's stance, making B correct.
The nurse is providing dietary instruction for a client with hypoglycemia. To prevent hypoglycemic reactions, the nurse should instruct the client to:
- A. Eat a candy bar if he feels lightheaded
- B. Always carry a quick source of sugar
- C. Limit his intake of fluids with meals
- D. Avoid eating large meals
Correct Answer: B
Rationale: Carrying a quick sugar source (e.g., glucose tabs) prevents hypoglycemic reactions by rapidly raising blood sugar candy is less precise, fluid limits are unrelated, and large meals don't directly cause drops. Nurses teach this, ensuring safety, critical for hypoglycemia management.