Nokea
You are the supervising nurse in a physical rehabilitation center that has the philosophy that clients have the need to cope with their disabilities and its limitations are the result of a discrepancy between the client's abilities and the limitations of the physical and social environment within which the client lives. Which model of disability is this philosophy based on?
- A. Orem's Self Care Model
- B. Nagis Model
- C. A cognitive model of disability
- D. A biomedical model of disability
Correct Answer: C
Rationale: This philosophy aligns with the cognitive model of disability, which emphasizes the interaction between an individual's abilities and environmental barriers, focusing on adaptation and coping strategies.
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The nurse reviews the serum laboratory results for a client prescribed hydrochlorothiazide. Which most frequent side effect of this medication should the nurse specifically monitor for?
- A. Hypokalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: The client taking a potassium-losing diuretic must be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with the use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia.
A client with iron deficiency anemia is taking iron supplements. The nurse emphasizes to the client that the drug will have increased absorption if taken with:
- A. Milk
- B. Orange juice
- C. Food
- D. Beta-carotene
Correct Answer: B
Rationale: Iron absorption is enhanced by vitamin C, found in orange juice, while milk and food can decrease absorption. Beta-carotene does not significantly affect iron absorption.
A nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician immediately?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Jaundice on the face
Correct Answer: D
Rationale: Jaundice within 24 hours of birth is pathological and requires immediate evaluation. Milia, Mongolian spots, and caput succedaneum are normal findings.
A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
- A. Check the sodium level.
- B. Call the primary health care provider.
- C. Encourage an extra 500 mL of fluid intake.
- D. Teach the client about foods low in potassium.
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
The nurse is instructing an unlicensed assistive personnel on the prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has understood the nurse's instructions?
- A. I will turn the client every 4 hours.'
- B. I will keep the client's head elevated.'
- C. I should suction the client every 2 hours.'
- D. I will have the client take 5 to 10 deep breaths every hour.'
Correct Answer: D
Rationale: Deep breathing exercises hourly prevent atelectasis and promote lung expansion, key to preventing pulmonary complications.