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1. Which of the following values should be monitored closely while a client is on total parenteral nutrition?
- A. calcium
- B. magnesium
- C. glucose
- D. cholesterol
Correct answer: C
Rationale: Glucose is the correct value to monitor closely while a client is on total parenteral nutrition. Total parenteral nutrition solutions have high glucose concentrations, necessitating monitoring to prevent complications like hyperglycemia. Calcium, magnesium, and cholesterol are not typically closely monitored during total parenteral nutrition as they are not directly related to the solution's composition or potential associated complications.
2. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?
- A. Iris
- B. Cornea
- C. Optic disc
- D. Conjunctiva
Correct answer: C
Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.
3. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
- B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. The organ procurement organization makes the decision regarding which organs to harvest.
- D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.
Correct answer: A
Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.
4. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?
- A. Trochlear nerve
- B. Abducens nerve
- C. Trigeminal nerve
- D. Oculomotor nerve
Correct answer: C
Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.
5. A nurse, assigned to care for a hospitalized child who is 8 years old, assists with planning care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child?
- A. Developing a sense of control over self and body functions
- B. Mastering useful skills and tools
- C. Gaining independence from parents
- D. Developing a sense of trust in the world
Correct answer: B
Rationale: According to Erikson's theory of psychosocial development, the primary task for an 8-year-old child aligns with the stage of industry versus inferiority. This stage focuses on mastering useful skills and tools of the culture, emphasizing competence in various areas. Option A, 'Developing a sense of control over self and body functions,' is more characteristic of the toddler stage, emphasizing autonomy and self-regulation. Option C, 'Gaining independence from parents,' is more relevant to the adolescent stage, where identity development and autonomy become crucial. Option D, 'Developing a sense of trust in the world,' pertains to the infant stage, highlighting the importance of forming secure attachments. Therefore, the correct answer is B as it directly corresponds to the developmental tasks associated with an 8-year-old child according to Erikson's theory.
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