Which phenomena is defined as "a subjective human experience that is what the client says it is, exists when the client says it is present, and it alerts humans to actual or potential bodily tissue damage"?

A. Anxiety

B. Pain

C. Fear

D. Perception

Choice B is correct. Pain is defined as a subjective human experience that is what the client says it is, exists when the client says it is present, and alerts humans to actual or potential bodily tissue damage. It is an unpleasant and distressing experience that has both physical and emotional components.

Choice A is incorrect. Anxiety is a psychological and emotional response to an anticipated threat to self that leads to unpleasant feelings such as feelings of dread.

Choice C is incorrect. Fear is defined as the emotional response to actual and present danger.

Choice D is incorrect. Perception is defined as the human being’s ability to interpret the environment exterior to the person as interpreted by the person’s senses, including hearing, vision, and tactile sensation.

225) ANSWER

A) Tinea corporals

RATIONALE

Tinea corporals are a fungal infection of the body called ringworm. The most common lesions are large, circular patches with raised, red borders of vesicles, papules, or pustules. This question requires knowledge of tinea.

224) ANSWER

B) High Risk for Deficient Fluid Volume

RATIONALE

The client with DIC is at risk for hemorrhage, which takes priority over the non-life-threatening options 1 and 4. The client could experience bruising or other areas of local bleeding from the disorder, but hypovolemia from hemorrhage takes priority over risk for injury (option 3). The issue of the question is knowledge of complications of DIC, specifically hemorrhage and loss of circulating volume. With this in mind, focus on physiologically based nursing diagnoses, and eliminate options 1 and 4. Choose option 2 because it addresses a greater and more specific physiological risk.

223) Answer

B. B. With 15 minute intervals, the nurse begins to position patient into high-fowler’s, then instructs her to dangle her feet at the bedside, after this, she assists her to move from the bed to the chair and then, walk with her around the room.

Rationale

•Early walking after surgery prevents the development of complications. The nurse facilitates proper ambulation when she instructs the patient to perform leg exercises while in bed and positions her to high-Fowlers.

•Then, the patient is instructed to dangle her feet at the bedside. The patient may feel dizzy, nauseated, or faint so it must be performed slowly and with long intervals in between. Then, the patient is moved from the bed to the chair and should be assisted to walk around the room.

•Other options show inappropriate ambulation because the procedure was done too quickly and non-systematically.

222) Answer

B. Avoiding contact with people who have upper respiratory infections

Rationale

•Acute otitis media generally follows a respiratory infection, it is important to avoid contact with people having upper respiratory infections.

•Inflammation of the middle ear is the most prevalent disease of childhood after respiratory infections.

•There is a higher incidence of acute otitis media in formula-fed infants than those who are breast-fed because of the more slanted position that formula-fed infants are held in while feeding. This allows milk to enter the Eustachian tube.

•Most cases of acute otitis media are caused by bacteria and treated with antibiotics such as amoxicillin. If the infection is viral, antivirals are reserved for severe cases only.

221) Answer
B. Urine concentration

Rationale
•ADH concentrates the urine by reabsorbing water in the renal tubule aquaporins.
•Sodium reabsorption and potassium excretion is the responsibility of aldosterone.v

220) Answer
A. Administering I.V. therapy


Rationale
•Administering I.V. fluids and medication is USUALLY beyond the scope of an LPN. The LPN must have special training in order to administer I.V. fluids.
•The other options are all within the scope of an LPN.