Nokea
You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model?
- A. The Biophysical Dimension
- B. The Psychological and Emotional Dimension
- C. The Spiritual Dimension
- D. The Health Systems Dimension
Correct Answer: D
Rationale: The Dimensions Model of Health typically includes biophysical, psychological, social, and spiritual dimensions. The Health Systems Dimension is not a standard component of this model.
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A client complains of a dull headache and dizziness and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide,50 mm Hg; and bicarbonate, 24 mEq/L. These findings indicate which of the following acid-base imbalances?
- A. Respiratory alkalosis
- B. Respiratory acidosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: A pH of 7.26 (acidic) with elevated CO2 (50 mm Hg) and normal bicarbonate (24 mEq/L) indicates respiratory acidosis, likely due to hypoventilation. Other imbalances do not match these values.
The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses?
- A. Imbalanced nutrition: Less than body requirements.
- B. Acute pain related to abdominal muscle spasms.
- C. Adult failure to thrive.
- D. Ineffective health maintenance.
Correct Answer: A
Rationale: Poor appetite, nausea, and vomiting indicate inadequate nutritional intake, supporting the diagnosis of imbalanced nutrition.
When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
- A. I need to stay out of the sunlight for 3 days.
- B. The injection site may itch, but I can scratch it if I need to.
- C. I need to avoid sexual intercourse for 2 to 3 days after the vaccination.
- D. I need to prevent becoming pregnant for 2 to 3 months after the vaccination.
Correct Answer: D
Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.
A client with a history of chronic renal failure is prescribed epoetin alfa (Epogen). The nurse should monitor the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hypoglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Epoetin alfa can cause hypertension due to increased red blood cell production, requiring close monitoring.
A client with a history of depression is prescribed paroxetine (Paxil). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Suicidal thoughts.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Suicidal thoughts are a serious side effect of paroxetine, requiring immediate reporting to ensure client safety.