Nokea
What is the first action the nurse should take?
- A. Start an IV lines for fluids
- B. Get an ECG
- C. Place a Foley catheter
- D. Check for neurologic status
Correct Answer: D
Rationale: The first action the nurse should take is to check for neurologic status. This is essential in assessing the patient's level of consciousness, orientation, motor function, and pupil responses. It helps determine if the patient is experiencing neurological issues such as a stroke, which would require immediate medical attention. Checking neurologic status is a priority because it guides the nurse in identifying the next steps for the patient's care.
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Which of the following data would be included in a health history? (Select all that apply.)
- A. Review of systems
- B. Physical assessment
- C. Sexual history
- D. Growth measurements
Correct Answer: A
Rationale: A health history is a comprehensive compilation of information about a patient's health status, medical conditions, and pertinent background information. The selected data that would be included in a health history includes:
Mr. RR is being prepared for surgery. Nursing care would include:
- A. Careful assessment of neurologic signs to establish baseline data for post-operative care
- B. Planning activities for Mr. RR
- C. Administration of an SS enema to prevent post-operative impaction
- D. Explaining to Mr. RR post-operative complications
Correct Answer: A
Rationale: Nursing care for a patient being prepared for surgery includes conducting a careful assessment of neurologic signs to establish baseline data for post-operative care. Assessing the patient's neurologic status preoperatively is important for early detection of any post-operative complications such as changes in consciousness, sensation, or movement. This baseline data will be used to monitor and evaluate the patient's recovery and response to the surgery, anesthesia, and post-operative care interventions. Planning activities, administering enemas, and explaining post-operative complications are also important aspects of nursing care but assessing neurologic signs is the priority in this scenario.
Which is now referred to as the "new morbidity"?
- A. Limitations in the major activities of daily living
- B. Unintentional injuries that cause chronic health problems
- C. Discoveries of new therapies to treat health problems
- D. Behavioral, social, and educational problems that alter health
Correct Answer: D
Rationale: The term "new morbidity" is now used to describe the impact of behavioral, social, and educational factors on health outcomes. This concept acknowledges that health is not solely determined by physical health conditions but also by one's behaviors, social circumstances, and education levels. Factors such as smoking, substance abuse, stress, lack of education, poverty, and social inequalities can significantly influence an individual's health. Recognizing and addressing these non-traditional health determinants are crucial in promoting overall health and well-being.
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: A
Rationale: Cystoclisis refers to the continuous irrigation of the bladder with a sterile solution to maintain bladder atony. This procedure is commonly done to provide continuous bladder drainage, prevent clot formation, and promote urinary flow. By continuously irrigating the bladder, it helps to keep the bladder decompressed and prevent the overdistension of the bladder muscles, especially in patients with impaired bladder emptying or bladder dysfunction. Therefore, the purpose of cystoclisis is to increase bladder atony rather than the other options listed.
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
- A. insulin.
- B. poatassium chloride.
- C. furosemide (Lasix)
- D. vasopressin (Pitressin).
Correct Answer: D
Rationale: Diabetes insipidus is a condition characterized by the inability of the kidneys to conserve water, leading to excessive urination and extreme thirst. The main treatment for diabetes insipidus is the administration of vasopressin (also known as antidiuretic hormone or ADH). Vasopressin helps the kidneys retain water, reduce urine output, and stabilize the body's fluid balance. Therefore, in caring for a client with diabetes insipidus, the nurse should anticipate the administration of vasopressin to help manage the symptoms of excessive urination and dehydration.