What parts make up and work together in Imogene King's Theory of Goal Attainment? (Select all that apply.)
a. Creating a method to evaluate outcomes
b. Defining quality nursing care
c. Setting goals
d. Focusing on self-care
e. Maintaining a clean environment
ANS: A, B, C
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A nurse is assessing the plantar reflex in a patient. Which of the following results would indicate abnormal response and a possible lesion in the pyramidal tract? Select all that apply
A) Plantar flexion of all toes B) Dorsiflexion of the big toe with fanning of the other toes C) No response at all D) Dorsiflexion of the big toe without fanning of the other toes E) Ticklishness
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L
Should the nurse start salt tablets when caring for this client? A) Yes, this will correct the sodium deficit. B) Yes, along with the hypotonic IV. C) No, start with the sodium chloride IV. D) No, sodium intake should be restricted.
The nurse is caring for an asthmatic patient with a nursing diagnosis of "Impaired gas exchange related to air trapping." The intervention that would be appropriate to add to the nursing care plan is to:
1. provide postural drainage. 2. administer oxygen at 8 L/minute. 3. position flat in bed with small pillow. 4. increase fluid intake.
What are indications for a referral regarding a communication impairment in a school-age child? (Select all that apply.)
a. Barely audible voice quality b. Vocal pitch inappropriate for age c. Intonation noted during speaking d. Maintains a rhythm while speaking e. Distortion of sounds after age 7 years