Nokea
Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?
- A. The patient or their healthcare proxy
- B. Only the patient
- C. Only the healthcare proxy
- D. The doctor
Correct Answer: C
Rationale: When a patient is unable to make decisions due to mental incapacity, the healthcare proxy, designated by the patient in advance, has the legal authority to make decisions on the patient's behalf. In this situation, the patient lacks the capacity to make decisions independently. The healthcare proxy's role is to represent the patient's wishes and best interests. The doctor's role in a patient care conference is to provide medical expertise, offer recommendations, and assist in the decision-making process, but the final decision-making authority lies with the healthcare proxy, not the doctor.
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Which of the following is a negative outcome associated with impaired mobility?
- A. Increased amounts of calcium are absorbed from circulation
- B. A drop in blood pressure occurs when rising from a sitting to a standing position
- C. The amount of mucus in the bronchi and lungs decreases
- D. The vessel walls of the circulatory system thicken
Correct Answer: B
Rationale: A client with impaired mobility may develop changes in body systems that put them at risk of further illness or injury. One negative outcome associated with impaired mobility is orthostatic hypotension, where blood pressure drops significantly when moving from a sitting or lying position to a standing position. This drop in blood pressure can lead to symptoms such as dizziness or fainting. This occurs because blood circulates more slowly or pools in the distal extremities due to impaired mobility.
Choice A is incorrect because increased calcium absorption is not a typical negative outcome associated with impaired mobility.
Choice C is incorrect because a decrease in mucus in the bronchi and lungs is not a common negative outcome of impaired mobility.
Choice D is incorrect because thickening of vessel walls in the circulatory system is not directly associated with impaired mobility.
A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: C
Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
Which of the following is classified as a prerenal condition that affects urinary elimination?
- A. Nephrotoxic medications
- B. Pericardial tamponade
- C. Neurogenic bladder
- D. Polycystic kidney disease
Correct Answer: B
Rationale: A prerenal condition is one that causes reduced urinary elimination by affecting the blood flow to the kidneys. Pericardial tamponade is a condition that impacts the heart's ability to pump sufficient blood, leading to decreased blood flow to vital organs such as the kidneys. This reduction in blood flow to the kidneys can result in decreased urine production. The other choices, such as nephrotoxic medications, neurogenic bladder, and polycystic kidney disease, do not primarily affect the blood flow to the kidneys and are not classified as prerenal conditions that impact urinary elimination.
A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?
- A. Is something wrong with the bath water?
- B. Just calm down, we'll finish your bath soon.
- C. Are you trying to tell me something?
- D. Shall I turn on the television?
Correct Answer: A
Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.
Your patient has finished a 12-ounce can of iced tea and 8 ounces of fresh orange juice. What will you record on the Intake and Output form for this patient's intake?
- A. 20 cc
- B. 20 cm
- C. 600 cc
- D. 600 cm
Correct Answer: C
Rationale: You will record 600 cc of fluid intake. There are 600 cc in 20 ounces (12 ounces of iced tea + 8 ounces of orange juice) of fluid intake. Choice A and B are incorrect as they do not reflect the correct conversion of fluid intake from ounces to cubic centimeters. Choice D is incorrect as it provides the measurement in cubic centimeters but does not account for the total fluid intake accurately.