Nokea
Which of the following statements is a characteristic of the clinical practice guidelines for infants and children for a periodic health examination?
- A. They are used to diagnose an illness.
- B. They are helpful in identifying developmental delays in children.
- C. They recommend that every individual receive an annual physical examination.
- D. They list a frequency schedule for periodic health visits for a specific age group.
Correct Answer: D
Rationale: The correct answer is D because clinical practice guidelines for periodic health examinations provide a frequency schedule for health visits based on age. This is crucial for ensuring timely preventive care and monitoring of growth and development. Choice A is incorrect as guidelines focus on preventive care, not diagnosing illnesses. Choice B is incorrect because while guidelines may mention developmental milestones, their primary focus is on health maintenance. Choice C is incorrect as guidelines recommend health visits based on individual needs, not a one-size-fits-all annual physical examination.
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When formulating diagnostic statements, what would the nurse use?
- A. Rationale
- B. American Nurses Association recommendations
- C. Physical assessment skills
- D. Diagnostic reasoning
Correct Answer: D
Rationale: The correct answer is D: Diagnostic reasoning. When formulating diagnostic statements, nurses use diagnostic reasoning to analyze data, identify patterns, and make accurate clinical judgments. This process involves critical thinking and synthesizing information to reach a conclusion. Physical assessment skills (C) are important in data collection but not the primary focus in formulating diagnostic statements. Rationale (A) refers to providing reasons or justifications and is not directly related to the diagnostic process. American Nurses Association recommendations (B) may guide nursing practice but are not specifically used in formulating diagnostic statements.
What should be the nurse's first priority for a client with an open wound?
- A. Clean and dress the wound
- B. Administer pain relief
- C. Administer anticoagulants
- D. Monitor blood pressure
Correct Answer: B
Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.
A patient with heart failure tells the nurse, "I can't breathe very well at night." The nurse should ask:
- A. "Is the breathing difficulty worse when you're lying down?"
- B. "What has been the duration of your breathing problems?"
- C. "Do you feel short of breath during the day as well?"
- D. "Have you had any previous episodes of difficulty breathing?"
Correct Answer: A
Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.
What should the nurse do first when caring for a client with a suspected spinal cord injury?
- A. Immobilize the spine
- B. Place the client in a supine position
- C. Administer analgesics
- D. Assess the airway
Correct Answer: A
Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.
What is the most important nursing intervention for a client with severe dehydration?
- A. Administer IV fluids
- B. Monitor vital signs
- C. Provide oral rehydration
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. This is the most important nursing intervention for a client with severe dehydration because IV fluids provide rapid rehydration and help restore electrolyte balance efficiently. Monitoring vital signs (choice B) is important but not as crucial as providing immediate fluid replacement. Providing oral rehydration (choice C) may not be effective for severe dehydration as the client may have difficulty absorbing fluids orally. Administering oxygen (choice D) is not directly related to treating dehydration, so it is not the most important intervention in this scenario.