Nokea
Which triage assessment prioritizes the client’s need for treatment as the need to be seen now?
- A. Delayed
- B. Immediate
- C. Minimal
- D. Expectant
Correct Answer: B
Rationale: The correct answer is B because immediate triage indicates the client requires urgent treatment.
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Nursing diagnoses mostly differ from medical diagnoses, in that they are
- A. dependent upon medical diagnoses for the direction of appropriate interventions.
- B. primarily concerned with caring, while medical diagnoses are primarily concerned with curing.
- C. primarily concerned with human response, while medical diagnoses are primarily concerned with pathology.
- D. primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters.
Correct Answer: C
Rationale: Nursing diagnoses focus on the patient's response to health conditions, whereas medical diagnoses focus on the disease itself.
What sign would you expect to find when assessing Mr. Stout with chronic bronchitis?
- A. Loss of weight
- B. Chronic cough
- C. Barrel chest
- D. Scanty sputum
Correct Answer: B
Rationale: Chronic cough is a hallmark symptom of chronic bronchitis.
Which adaptations for performing the examination would be appropriate for the patient (select all that apply)?
- A. Make sure that a family member is with him.
- B. Handle the skin with care because of potential fragility.
- C. Keep the patient warm and comfortable during the assessment.
- D. Allow the patient to watch TV to distract him from any painful assessments.
Correct Answer: C
Rationale: The correct answers are 'Handle the skin with care because of potential fragility,' 'Keep the patient warm and comfortable during the assessment,' and 'Place the patient in a position of comfort and avoid unnecessary changes in position.' These adaptations address age-related vulnerabilities and promote patient cooperation.
Donna is a healthy, 38-year-old woman scheduled for elective surgery next week. During the preoperative clearance, the physician, nurse practitioner, or physician assistant would include which of the following in her preoperative preparation?
- A. Pulmonary function test and chest x-ray.
- B. Complete blood count, metabolic panel, and pregnancy test.
- C. Urine culture, thyroid panel, and cortisol level.
- D. Glucose tolerance test, ankle-brachial index, and electrocardiogram (EKG).
Correct Answer: B
Rationale: Elective surgeries typically require basic preoperative tests such as a complete blood count (CBC), metabolic panel, and pregnancy test to ensure the patient is fit for surgery. Pulmonary function tests and other specialized tests are usually reserved for patients with specific risk factors.
Until doctor's orders are received, the most appropriate position for Mr. Jones, admitted with retinal detachment, is lying
- A. flat on his back
- B. on his left side
- C. on his right side
- D. on his abdomen
Correct Answer: B
Rationale: Lying on the affected side (left side) helps reduce movement of the detached retina, minimizing further damage until definitive treatment can be administered.