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| Section | Weight | Objectives |
|---|---|---|
| Management of Care | 15-21% | - Management of Care
|
| Health Promotion and Maintenance | 6-12% | - Health Promotion and Maintenance
|
| Physiological Adaptation | 11-17% | - Physiological Adaptation
|
| Reduction of Risk Potential | 9-15% | - Reduction of Risk Potential
|
| Psychosocial Integrity | 6-12% | - Psychosocial Integrity
|
| Safety and Infection Control | 10-16% | - Safety and Infection Control
|
| Pharmacological and Parenteral Therapies | 13-19% | - Pharmacological and Parenteral Therapies
|
| Basic Care and Comfort | 6-12% | - Basic Care and Comfort
|
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NEW QUESTION # 559
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
Answer: B
Explanation:
(A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.
NEW QUESTION # 560
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. (B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. (C) Dactylitis crisis, or "hand-foot syndrome," causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. (D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
NEW QUESTION # 561
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?
Answer: A
Explanation:
Section: Questions Set F
Explanation:
(A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.
NEW QUESTION # 562
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
Answer: B
Explanation:
(A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them.
NEW QUESTION # 563
When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
Answer: D
Explanation:
Explanation
(A) The nurse must be honest, direct, professional, and attentive in her interview to gain the parent's trust. (B) The nurse should approach the parents in private, away from the child. (C) Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child's "accident." At this point, the parents may get defensive and stop communicating. (D) Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.
NEW QUESTION # 564
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