Nokea
Which statement about targeted assessments is accurate?
- A. The need for a targeted assessment is based on the application of the nurse's knowledge of pathophysiology and the presenting symptoms.
- B. The need for a targeted assessment is based on the application of the nurse's knowledge of developmental needs and developmental delays.
- C. Targeted assessment is done on an annual basis for existing clients rather than a complete assessment that is done for new clients.
- D. Targeted assessments consist of a brief medical history and a complete assessment consists of a complete health history and a complete physical assessment.
Correct Answer: A
Rationale: Targeted assessments focus on specific health issues based on the nurse's knowledge of pathophysiology and the patient's presenting symptoms, allowing for a focused evaluation rather than a comprehensive one.
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The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply.
- A. Vitamin K.
- B. Vitamin B6.
- C. Folate.
- D. Vitamin B12.
- E. Vitamin D.
Correct Answer: B, C, D
Rationale: Vitamin B6, folate, and vitamin B12 reduce homocysteine levels, a risk factor for coronary heart disease.
A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, 'What does that mean?' The nurse explains that a reactive nonstress test indicates which of the following about the fetus?
- A. Evidence of some compromise that will require delivery soon.
- B. Fetal well-being at this point in the pregnancy.
- C. Evidence of late decelerations occurring during the test.
- D. No accelerations demonstrated within a 20-minute period.
Correct Answer: B
Rationale: A reactive nonstress test, showing fetal heart rate accelerations, indicates fetal well-being.
A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse should ask the client about which symptom?
- A. Chest pain that is dull and feels like heartburn
- B. Leg pain that is sharp and occurs with exercise
- C. Chest pain that is sudden and occurs with exertion
- D. Leg pain that is achy and gets worse as the day progresses
Correct Answer: B
Rationale: Intermittent claudication is a symptom characterized by a sudden onset of leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Chest pain can occur for a variety of reasons, including indigestion or angina pectoris. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.
Which of the following is NOT an essential component of a restraint order?
- A. Informed consent for the restraint
- B. The reason for the restraint
- C. The type of restraint to be used
- D. Client behaviors that necessitated the restraints
Correct Answer: A
Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.
A 3-year-old is admitted with croup. Which intervention should the nurse prioritize?
- A. Administer racemic epinephrine
- B. Provide a high-calorie diet
- C. Encourage oral fluids
- D. Apply a warm compress to the throat
Correct Answer: A
Rationale: Racemic epinephrine is the priority for croup to reduce airway swelling and relieve stridor, addressing the immediate respiratory distress.