A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?

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Question 1 of 9

A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?

Correct Answer: B

Rationale: Acetic acid tests protein cloudiness not glucose; heating only acid (no urine) is wrong. Urine (2/3), heating with urine, cloudiness (protein) are correct. Nurses need correction e.g., purpose for accuracy, per procedure.

Question 2 of 9

When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck, the nurse should provide teaching regarding which of the following procedures?

Correct Answer: D

Rationale: Rhytidectomy (facelift) removes excess skin from face and neck.

Question 3 of 9

Which of the following statement best describe a health care proxy?

Correct Answer: B

Rationale: A health care proxy is a person chosen to decide (B), per definition e.g., surrogate for incapacity. Not diagnosis (A), policy (C), plan (D) decision-maker. B best defines proxy's role, like Mr. Gary appointing someone, making it correct.

Question 4 of 9

The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.

Correct Answer: A

Rationale: Post-hypophysectomy, nose blowing (A) risks CSF leak or meningitis by disrupting the surgical site. Brushing (B) and semi-Fowler's (D) are safe. Bending (C) is risky but less immediate. A is correct. Rationale: Nasal pressure can breach the pituitary fossa repair, a critical complication in early recovery, per post-operative neurosurgery care, unlike benign actions.

Question 5 of 9

When recording blood pressure, the sounds which can be heard with a stethoscope placed over the artery is termed as:

Correct Answer: D

Rationale: Blood pressure measurement involves listening to arterial sounds via a stethoscope as the cuff deflates. These sounds, known as Korotkoff sounds, occur in five phases, starting with a tapping (systolic pressure) and fading to silence (diastolic pressure). Wheezes are respiratory sounds, murmurs relate to heart valves, and crackles indicate lung fluid none apply to blood pressure. Named after Nikolai Korotkoff, these sounds are a cornerstone of manual blood pressure assessment, ensuring accurate readings essential for diagnosing hypertension or hypotension, reflecting cardiovascular health.

Question 6 of 9

An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?

Correct Answer: A

Rationale: Joint stiffness signals early contractures or atrophy from immobility.

Question 7 of 9

Which one of the following is the commonest side effects of copper-T :

Correct Answer: B

Rationale: Copper-T, an intrauterine device (IUD), has known side effects, with bleeding being the most frequent. Pain (choice A) occurs, especially during insertion or cramping, but it's typically transient. Bleeding (choice B), including heavier periods or spotting, affects most users due to copper's inflammatory effect on the endometrium, often leading to discontinuation. Perforation (choice C) is rare, occurring in <1/1000 insertions, and ectopic pregnancy (choice D) is a serious but uncommon risk, as IUDs primarily prevent intrauterine implantation. B is correct, as clinical data consistently show bleeding as the commonest complaint. Nurses must educate patients on expected bleeding patterns, monitor for anemia, and assess when intervention (e.g., removal) is needed, ensuring informed use of this contraceptive method.

Question 8 of 9

The nurse recorded Mr. Gary's vitals in his chart. This is an example of?

Correct Answer: A

Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.

Question 9 of 9

Which psychological effect is commonly observed in patients experiencing immobility?

Correct Answer: D

Rationale: Immobility often increases anxiety and depression risk, as patients face mobility loss, dependence, and isolation, fostering psychological distress. Motivation and independence typically wane with restricted activity, while depression risk rises, not falls, due to these constraints. Nurses address this through emotional support and engagement, understanding that mental health declines when physical freedom is curtailed. This effect highlights the need for holistic care, blending physical interventions with psychological support to mitigate the emotional toll of immobility on patients.

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