LPN exams fundamentals practice questions set 31

Correct answer:

Dorothea Orem's self-care theory posits that nurses assist clients in performing self-care activities to maintain or improve health, emphasizing individual responsibility and nursing support when deficits arise. Developed in the mid-20th century, this theory frames nursing as a facilitative process, helping clients meet universal needs like air, water, and food, or recover from illness through tailored interventions. Florence Nightingale focused on environmental modifications to aid healing, not self-care. Virginia Henderson's Need Theory defines nursing as assisting with basic needs until independence is regained, differing from Orem's self-care focus. Sister Callista Roy's Adaptation Model centers on adjusting to stimuli, not self-care per se. Orem's framework remains influential, guiding nurses to empower clients in managing their health, particularly in chronic or rehabilitative contexts, by fostering independence and collaboration.

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Erik Erikson's theory of psychosocial development underpins pediatric assessments of children's growth, focusing on eight stages tied to age-specific conflicts like trust versus mistrust in infancy. In a pediatric practice, a nurse uses this to gauge if a child's social and emotional milestones align with norms, assessing interactions or independence. Erikson integrates social, biological, and environmental factors, offering a lifespan lens ideal for children. Jean Watson's caring theory emphasizes interpersonal healing, not development. Martha Rogers' model centers on energy fields and client-environment interplay, less stage-focused. Abraham Maslow's hierarchy of needs prioritizes physical and psychological needs hierarchically, not age-based progression. Erikson's framework provides nurses a structured, age-sensitive tool to evaluate and support psychosocial health, critical for tailoring care to young clients' evolving capabilities.

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ART is recommended for all listed conditions history of AIDS-defining illness, pregnancy, and hepatitis B co-infection reflecting universal treatment guidelines (e.g., WHO 'test and treat'). For AIDS-defining illnesses (e.g., Kaposi sarcoma), ART restores CD4 counts and cuts mortality by over 50% within a year (ACTG 5164). Pregnant women require ART to prevent MTCT, achieving <1% transmission with regimens like tenofovir-based therapy (HPTN 052). Hepatitis B co-infection benefits from ART drugs (e.g., tenofovir, lamivudine) that treat both viruses, reducing liver damage (Hepatology studies). Option D, 'all of the above,' aligns with evidence that immediate ART, regardless of CD4 count, improves outcomes e.g., START trial showed 57% risk reduction in serious events. Each condition independently warrants ART, but their collective inclusion reflects modern practice's comprehensive approach, making D the most accurate and supported choice.

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The correct answer is B: Monitor the patient for changes in neurological status. This is the priority intervention because patients with a history of stroke are at risk for complications such as recurrent strokes or worsening neurological status. Monitoring for changes allows for early detection and timely intervention. A: Assisting with a swallowing assessment is important, but monitoring neurological status takes precedence as it directly assesses the patient's brain function. C: Having a family member for rehabilitation is beneficial but not the priority over monitoring neurological status for immediate complications. D: Providing medication for swallowing improvement may be necessary, but monitoring neurological status is crucial for detecting any emergent issues. In summary, monitoring neurological status is the priority as it directly assesses the patient's brain function and allows for early detection of complications.

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The nurse should assess the patient with possible lung cancer who has just returned after bronchoscopy first because this patient may be at risk for complications such as bleeding, respiratory distress, or infection post-procedure. Assessing this patient promptly allows for early identification and intervention if any issues arise. The other choices present conditions that may require assessment but do not have the immediate post-procedure risk associated with bronchoscopy. The patient with pneumonia (choice A) may need assessment for respiratory status, but the urgency is lower than the post-bronchoscopy patient. The patient with chronic bronchitis (choice B) may require monitoring, but the low forced vital capacity does not indicate an acute issue. The patient with hemoptysis and a positive tuberculin skin test (choice D) may need further evaluation for tuberculosis, but the immediate risk is lower than the post-bronchoscopy patient.

Correct answer:

Pulmonary embolism (PE) risk post-surgery stems from venous stasis, a component of Virchow's triad, making early ambulation the most effective preventive measure. Walking within hours of surgery enhances venous return, prevents deep vein thrombosis (DVT) formation the primary PE source and counters immobility's prothrombotic effects. Increased protein intake aids wound healing but doesn't directly reduce clotting risk. Maintaining a supine position prolongs stasis, heightening DVT and PE likelihood, especially post-surgery when mobility is already limited. Combining aspirin with warfarin increases bleeding risk without superior PE prevention over warfarin alone, and anticoagulants are secondary to physical measures like ambulation. The nurse's focus on early mobilization, alongside elastic stockings or leg exercises, aligns with evidence-based protocols (e.g., SCIP guidelines), significantly lowering PE incidence in perioperative care.

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Hospital safety for a newly admitted client focuses on preventing falls, injuries, and disorientation, especially in an unfamiliar environment. Keeping side rails up at all times (C) is a key measure to prevent falls, particularly during sleep or if the client attempts to get out of bed unassisted, which is a common risk during initial hospitalization. Option A (removing unnecessary furniture) reduces clutter and tripping hazards but is less directly tied to immediate bedside safety. Option B (lights on at all times) may disrupt sleep and is impractical unless needed for observation, not universally ensuring safety. Option D (hiding equipment) may reduce anxiety but does not directly enhance physical safety and could hinder access to necessary tools. Side rails provide a physical barrier, aligning with evidence-based fall prevention protocols in hospitals, making C the most effective safety action for a first-time hospitalized client.

Correct answer:

The correct answer is A: Monitoring for decreased breath sounds on the affected side. This is the priority assessment because pneumothorax involves the accumulation of air in the pleural space, leading to lung collapse and decreased breath sounds on the affected side. This assessment is crucial to promptly detect worsening respiratory status and the need for immediate intervention. Choice B is incorrect because while assessing for bilateral chest rise and fall is important in general respiratory assessment, it is not the priority in pneumothorax where the focus is on the affected side. Choice C is incorrect as cyanosis and tachycardia may occur later as a result of respiratory distress, but monitoring breath sounds is more direct for detecting pneumothorax. Choice D is incorrect because measuring oxygen saturation levels may not accurately reflect the severity of pneumothorax and should not be the priority assessment in this case.

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The correct answer is A: Provide a structured mealtime environment with supervision. This is the most important initial intervention for a patient with bulimia nervosa because it addresses the immediate health concern of disordered eating behavior. By providing a structured mealtime environment with supervision, the patient can establish regular eating patterns, learn healthier eating habits, and reduce the risk of purging behaviors. This intervention also helps in restoring proper nutrition and addressing any underlying issues related to food and eating. Choice B is incorrect because support groups may be beneficial but are not the most critical initial intervention. Choice C is incorrect as antianxiety medications do not directly address the disordered eating behavior. Choice D is also incorrect as assessing family dynamics and home environment is important but not as crucial as addressing the immediate eating disorder symptoms.

Correct answer:

The correct answer is C. The client statement "I took all my meds including warfarin and atenolol with a sip of water this morning" needs immediate follow-up because warfarin is a blood thinner and atenolol is a beta-blocker, both of which can have implications for surgery. Warfarin increases the risk of bleeding during surgery and atenolol can affect heart function. The nurse needs to assess the timing of medication intake and coordinate with the healthcare team to manage these medications appropriately before surgery to prevent complications. Choice A is not the most immediate concern since it is common practice to fast before surgery to reduce the risk of aspiration. Choice B, while important, does not require immediate follow-up as long as the donation meets the facility's guidelines. Choice D, bringing a health care directive, is important but not as urgent as addressing medication intake that can directly impact the surgery.