Nokea
Your assigned client seems to be getting a lot of attention from his mother when he complains of pain. The mother may be encouraging which of the following types of gains?
- A. primary gains
- B. secondary gains
- C. narcissistic gains
- D. egocentric gains
Correct Answer: B
Rationale: Maternal attention for pain suggests secondary gains external benefits beyond primary relief or other gains. Nurses address this in behavioral pain management.
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An infant is born precipitously outside the labor room. What should the nurse do first?
- A. Tie and cut the umbilical cord
- B. Establish an airway for the newborn
- C. Ascertain the condition of the uterine fundus
- D. Arrange transport for the mother and infant to the birthing unit
Correct Answer: B
Rationale: Precipitous birth outside controlled settings demands urgent action. Tying/cutting the cord (choice A) is secondary; delay poses no immediate risk unless bleeding occurs. Establishing an airway (choice B) is first, as newborns must breathe independently clearing mucus or stimulating crying ensures oxygenation, critical within the golden minute. Checking the fundus (choice C) assesses maternal bleeding, a later priority. Transport (choice D) follows stabilization. B is correct, per neonatal resuscitation guidelines. Nurses clear airways, warm the infant, and then address cord and maternal needs, ensuring survival.
Which of the following statement is TRUE about do-not-resuscitate (DNR) orders?
- A. Stops all treatment
- B. Prevents CPR
- C. Only for emergencies
- D. All of the above
Correct Answer: B
Rationale: DNR prevents CPR (B), per definition specific to resuscitation. Not all treatment (A), not emergency-only (C), not all (D) focused order. B truly defines DNR's scope, like Mr. Gary's potential choice, ensuring no CPR if heart stops, making it correct.
Which of the following statement best describe incident reporting?
- A. Hiding errors
- B. Reporting adverse events
- C. A patient task
- D. A routine check
Correct Answer: B
Rationale: Incident reporting is reporting adverse events (B), per nursing e.g., falls logged. Not hiding (A), not task (C), not routine (D) safety-focused. B best defines its role, improving Mr. Gary's care safety, making it correct.
These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals.
- A. Dependent
- B. Independent
- C. Interdependent
- D. Intradependent
Correct Answer: C
Rationale: Interdependent interventions rely on multiple health professionals' expertise, such as a nurse, physiotherapist, and doctor co-managing a stroke patient's rehab plan. Dependent actions follow orders (e.g., giving meds), independent ones are nurse-initiated (e.g., repositioning), and 'intradependent' isn't a term. For instance, adjusting a patient's diet with a nutritionist reflects shared knowledge, ensuring holistic care. This collaboration, common in complex cases, leverages diverse skills, enhancing outcomes like mobility or nutrition, a hallmark of modern interdisciplinary healthcare teams.
The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of $20 \mathrm{mmHg}$. Which action made by the client is responsible for this condition?
- A. Drinking lots of water
- B. Eating high-fiber foods
- C. Bending over at the waist
- D. Bending knees when lowering body
Correct Answer: C
Rationale: ICP of 20 mmHg (elevated) post-hypophysectomy is likely from bending over (C), increasing venous pressure to the brain. Drinking (A) or eating fiber (B) don't directly raise ICP. Knee bending (D) is safe. C is correct. Rationale: Bending elevates intracranial venous return, spiking ICP in a fragile post-surgical state, per neurocare principles, unlike neutral activities.