Nokea
Which of the following would likely not impede learning?
- A. a client who took Ambien® an hour ago
- B. a bipolar client currently in a manic phase
- C. a client who states they are not interested
- D. a client with dysphagia
Correct Answer: C
Rationale: The correct answer is a client who states they are not interested. While lack of interest can hinder learning motivation, it is not a physical or mental barrier that directly impacts the learning process. On the other hand, a client who took Ambien® an hour ago may experience drowsiness or impaired cognitive function, affecting their ability to learn. A bipolar client in a manic phase may exhibit symptoms such as racing thoughts, distractibility, and impulsivity, making it challenging for them to focus and engage in the learning process. A client with dysphagia may have difficulty swallowing, which can interfere with their ability to take oral medications or participate in activities that involve swallowing.
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During the examination of a client's throat, a nurse touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which cranial nerves?
- A. Cranial nerves V and VI
- B. Cranial nerves XII and VIII
- C. Cranial nerves XII and VIII
- D. Cranial nerves IX and X
Correct Answer: D
Rationale: The correct answer is cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). When the nurse touches the posterior pharyngeal wall with a tongue blade and elicits the gag reflex, it indicates normal function of these nerves. Cranial nerves V (trigeminal nerve) and VI (abducens nerve) are not directly responsible for the gag reflex. Cranial nerves XII (hypoglossal nerve) and VIII (vestibulocochlear nerve) are not directly involved in eliciting the gag reflex. Testing cranial nerve I involves smell function, and cranial nerve II is related to eye examinations, making them irrelevant in this scenario.
What is the primary nutritional deficiency of concern for a strict vegetarian?
- A. vitamin C
- B. vitamin B12
- C. vitamin E
- D. magnesium
Correct Answer: B
Rationale: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian. While all mentioned vitamins are essential for overall health, vitamin B12 is particularly important for vegetarians as it is mainly found in animal products. A strict vegetarian diet may lack sufficient vitamin B12 intake, leading to potential health issues like anemia and neurological problems. Vitamin C deficiency is more commonly associated with scurvy, which is preventable with a diet rich in fruits and vegetables. Vitamin E deficiency is rare and usually only seen in specific medical conditions. Magnesium deficiency is not typically a primary concern for strict vegetarians as magnesium can be obtained from a variety of plant-based sources.
When caring for a patient who is hard-of-hearing, which of the following steps may be appropriate when communicating with the patient?
- A. Divide the verbal communication into smaller sections and address one at a time.
- B. Communicate only with written information.
- C. Ask multiple questions in a row quickly to make sure the patient is remaining engaged.
- D. Frequently communicate without assistive devices to help the patient improve their hearing.
Correct Answer: A
Rationale: When caring for a patient who is hard-of-hearing, it is important to divide verbal communication into smaller sections and address them one at a time. This approach helps the patient follow along more easily and understand the information being conveyed. While using written information can also be beneficial, solely relying on written communication may not always be practical or feasible for effective interaction. Asking multiple questions quickly can overwhelm the patient and hinder their ability to process each question adequately. It is essential to give the patient sufficient time to comprehend and respond. Additionally, frequently communicating without assistive devices is not recommended. Using assistive devices can significantly enhance the patient's ability to hear and understand, promoting better communication and patient care.
What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.
The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler's position for 30 minutes following the administration of the medications.
- C. The client mixes each medication separately in warm water.
- D. The client mixes their medications with their tube-feeding formula.
Correct Answer: D
Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.