FREE NNAAP Basic Nursing Skills Questions and Answer
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
A sense of impending doom is a common and characteristic symptom of panic attacks in individuals with panic disorder. It is often described as an overwhelming feeling of fear, apprehension, or impending catastrophe. This symptom distinguishes panic disorder from other anxiety disorders. Compulsive behavior, fear of flying, and predictable episodes may be associated with other anxiety disorders but are not as specific to panic disorder.
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
Artifact can mimic ventricular fibrillation on a cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client’s pulse.
The nursing care plan for a client with decreased adrenal function should include
For a client with decreased adrenal function, such as in Addison's disease or secondary adrenal insufficiency, the nursing care plan should include measures to prevent constipation. Decreased adrenal function can lead to gastrointestinal symptoms, including a sluggish bowel due to reduced cortisol levels, which can necessitate measures to promote regular bowel movements.
What needs of a patient does a nurse address?
Nurses address a patient's physical needs through medical care, administer emotional support to alleviate stress, and attend to mental well-being by considering cognitive aspects. Their holistic approach ensures comprehensive care, fostering overall health and recovery for individuals under their supervision.
Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
Tachypnea is a medical term used to describe rapid and shallow breathing, characterized by a respiratory rate greater than 20 breaths per minute. In Jake's case, his respiratory rate of 30 breaths per minute indicates tachypnea. This condition can be a symptom of various underlying health issues, such as heart or lung problems, infection, or anxiety. The nurse's documentation of Jake's tachypnea will help inform the healthcare team of his condition and guide further assessment and treatment.
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to
Anhedonia is a key symptom of depression and is characterized by a diminished ability to experience pleasure or interest in activities that were previously enjoyable. It can affect various aspects of life, including hobbies, social interactions, and other activities that used to bring joy. The other options, such as difficulty sleeping, persistent suicidal thoughts, and reduced senses of taste and smell, are associated with depression but do not specifically represent anhedonia.
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
Increasing oral fluid intake to 3000 cc per day is a reasonable and supportive intervention for a client with pneumococcal pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to mobilize and clear. While chest physiotherapy is a more direct method for removing secretions, promoting hydration is a valuable complementary measure. It is essential to consider a holistic approach to care, combining strategies that support both hydration and respiratory clearance for optimal outcomes in pneumonia management.
Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones?
Engorgement of the breasts is an example of a variation in the newborn resulting from the presence of maternal hormones. During pregnancy, maternal hormones stimulate the development of the mammary glands in the fetus. After birth, the sudden withdrawal of these hormones can lead to breast engorgement in both male and female infants. This is a temporary and normal variation that typically resolves on its own as the infant's body adjusts to the postnatal environment.
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds
CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for Disease Control defined AIDS as having a positive HIV plus one of these – the presence of an opportunistic infection or a CD4 lymphocyte count of less than 200.
A nurse evaluating a special needs 2-year-old in a clinic should stress which goal when talking to the child's mother?
Promoting optimal development is a key focus in the care of special needs children. This involves addressing the child's individual needs, milestones, and abilities, and providing interventions and support to maximize their overall development. While aspects of self-care skills and toileting may be part of the child's development plan, the overarching goal is to ensure the child reaches their highest potential in all aspects of growth and development.
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
Elevating the leg on two pillows is a nursing intervention commonly used to manage thrombophlebitis. By elevating the leg, the goal is to reduce swelling and enhance venous return, helping to alleviate symptoms and promote healing. This position aids in preventing stasis of blood in the affected leg and may contribute to overall comfort.