Saturday, 17 August 2019

Question Of The Day, Neurosensory Disorders
Q. When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

A. Trendelenburg's
B. 30-degree head elevation
C. Flat
D. Side-lying



Correct Answer: B

Explanation: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.


Friday, 16 August 2019

Question Of The Day, Gastrointestinal Disorders
Q. Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?

A. The client will be maintained on bed rest for several days.
B. Ambulation is restricted by the presence of drainage tubes.
C. The operative incision is near the diaphragm.
D. The presence of a nasogastric tube inhibits deep breathing.

Correct Answer: C

Explanation: The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep breathing and coughing.

Wednesday, 14 August 2019

Question Of The Day, Mood, Adjustment, and Dementia Disorders
Q. A nurse is facilitating mandated group therapy for clients who have sexually abused children. Children who are victims of sexual abuse are typically:

A. from any segment of the population.
B. of low socioeconomic background.
C. strangers to the abuser.
D. willing to engage in sexual acts with adults.



Correct Answer: A

Explanation: Victims of childhood sexual abuse come from all segments of the population and from all socioeconomic backgrounds. Most victims know their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full decision-making capacities.

Tuesday, 13 August 2019

Q. A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved?

A. The entry should include clearer descriptions of the client's mood and behavior.
B. The entry should avoid mentioning cognitive or psychosocial issues.
C. The entry should list the specific reasons that the client was upset.
D. The entry should specify the subsequent interventions that were performed.

Correct Answer: A

Explanation: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.


Monday, 12 August 2019

Q. A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it:

A. Purges evil spirits.
B. Promotes tranquility.
C. Restores the balance of energy.
D. Blocks nerve pathways to the brain.

Correct Answer: C

Explanation: Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.

Saturday, 10 August 2019

Question Of The Day, Neurosensory Disorders
Q. A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

A. Sit with the client for a few minutes.
B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the physician immediately.



Correct Answer: D

Explanation: The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary. 

Friday, 9 August 2019

Question Of The Day, Gastrointestinal Disorders
Q. A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?

A. Lean beef.
B. Air-popped popcorn.
C. Hot chocolate.
D. Raw vegetables.

Correct Answer: C

Explanation: With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.

Thursday, 8 August 2019

Q. A woman who has recently immigrated from Africa who delivered a term neonate a short time ago requests that a "special bracelet" be placed on the baby's wrist. The nurse should:

A. Tell the mother that the bracelet is not recommended for cleanliness reasons.
B. Apply the bracelet on the neonate's wrist as the mother requests.
C. Place the bracelet on the neonate, limiting its use to when the neonate is with the mother.
D. Recommend that the mother wait until she is discharged to apply the bracelet.

Correct Answer: B

Explanation: The nurse should abide by the mother's request and place the bracelet on the neonate. In some cultures, amulets and other special objects are viewed as good luck symbols. By allowing the bracelet, the nurse demonstrates culturally sensitive care, promoting trust. The neonate can wear the bracelet while with the mother or in the nursery. The bracelet can be used while the neonate is being bathed, or if necessary and acceptable to the client removed and replaced afterward.

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