Nokea
Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain?
- A. Offering the client pamphlets on support groups for brain cancer
- B. Asking the client if there is anything he or his family needs
- C. Reminding the client that advances in technology are occurring everyday
- D. Providing accurate information about the disease and treatment options
Correct Answer: D
Rationale: Accurate information empowers the client and family to make informed decisions.
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An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
What type of patient care model is the most common for student nurses and private duty nurses?
- A. Total patient care
- B. Team nursing
- C. Primary Nursing
- D. Case management
Correct Answer: A
Rationale: Total patient care, where one nurse handles all client needs like meds and hygiene is prevalent for student nurses and private duty nurses. Students benefit from focused, hands-on learning (e.g., managing a post-op patient solo), while private nurses provide personalized attention (e.g., home care). Team nursing splits tasks, primary nursing ensures continuity, and case management coordinates, but total care's simplicity suits training and one-on-one settings. Its direct accountability fosters skill mastery, widely used in educational and private contexts.
During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
- A. Place the probe on the child's abdomen
- B. Recalibrate the oximeter at the beginning of each shift
- C. Apply the probe and wait 15 minutes before obtaining a reading
- D. Place the probe on the child's finger
Correct Answer: D
Rationale: Placing the pulse oximeter probe on the finger ensures an accurate oxygen saturation reading in an 8-year-old, as peripheral sites like fingers provide reliable arterial pulsation data. The abdomen isn't suitable, recalibration isn't routine, and waiting 15 minutes delays care unnecessarily. Nurses use this technique for quick, precise monitoring, critical in respiratory infections to guide oxygen therapy.