Nokea
Which phase of the nurse-client relationship demonstrates a plan constructed mutually to meet goals identified during the assessment of the client?
- A. Termination phase
- B. Working phase
- C. Introductory phase
- D. Transition phase
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
A healthcare professional assesses a client who is experiencing an acute asthma attack. Which assessment finding requires immediate intervention?
- A. Loud wheezing
- B. Increased respiratory rate
- C. Use of accessory muscles
- D. Silent chest
Correct Answer: D
Rationale: The correct answer is D: Silent chest. This finding indicates severe airway obstruction and impending respiratory failure, requiring immediate intervention to prevent respiratory arrest. Silent chest means minimal or absent breath sounds, suggesting no air movement, which is a critical emergency situation. Wheezing (A), increased respiratory rate (B), and use of accessory muscles (C) are common in asthma attacks but do not indicate as severe a condition as a silent chest. Monitoring and addressing a silent chest promptly is crucial in managing acute asthma exacerbations.
A 29-year-old client is scheduled for an arthrotomy of the right knee following a football injury. The client describes his state of health as excellent and states that he does not use any medication. In providing psychological support for the client during the preoperative period, the nurse should:
- A. teach coughing and deep breathing exercises.
- B. provide for spiritual care, if appropriate.
- C. perform a head to toe assessment including height and weight.
- D. administer preoperative medication as ordered.
Correct Answer: B
Rationale: Teaching coughing and deep breathing is a component of preoperative teaching, but it does not necessarily provide psychological support. Spiritual care, a component of psychological support, can reduce the client's fears and anxieties related to the surgical experience. Performing a physical assessment is part of the physical preparation for surgery, not the psychological preparation. Providing the preoperative medication is a part of the preparation immediately before surgery. While the medication will sedate and relax the client, it is not considered to be psychological support.
Which of the following should be immediately reported to the physician?
- A. Change in color vision
- B. Crusty yellow drainage on eyelashes
- C. Increased lacrimation
- D. Curtain-like shadow across visual field
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which BMI is associated with overeating syndromes?
- A. Increase protein intake
- B. Reduce carbohydrate consumption
- C. Drink more water
- D. Take vitamin supplements
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?
- A. The client rates pain as 5/10 at the site of the procedure.
- B. A small amount of drainage is noted from the site.
- C. Pulse oximetry reads 93% on 2 liters of oxygen.
- D. The trachea is deviated toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because tracheal deviation indicates a potential tension pneumothorax, a life-threatening emergency requiring immediate intervention. Tracheal deviation occurs when there is a significant shift in the mediastinum due to increased pressure in the pleural space. This can compromise respiratory function and lead to respiratory failure. Options A, B, and C are not as urgent as tracheal deviation. Pain at 5/10 is expected post-thoracentesis, a small amount of drainage is common, and a pulse oximetry reading of 93% on low oxygen is concerning but not immediately life-threatening.