Nokea
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
- A. “Data interpretation occurs before data validation.”
- B. “Validation involves looking for patterns in professional standards.”
- C. “Validation involves comparing data with other sources for accuracy.”
- D. “Data interpretation involves discovering patterns in professional standards.”
Correct Answer: C
Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This step ensures that the data is reliable and error-free. Option A is incorrect as data validation typically comes after data collection and cleaning, which precede data interpretation. Option B is incorrect as validation does not specifically focus on professional standards but rather on accuracy and consistency. Option D is incorrect as data interpretation involves analyzing and deriving insights from the validated data, not looking for patterns in professional standards.
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When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client’s temperature before, during, and after transfusion
- B. Documenting the client’s temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client’s temp with the temp of the blood
Correct Answer: A
Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction.
Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction.
Incorrect choices:
B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction.
C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
- A. Is written as a two-part statement
- B. Describes human response to a health problem
- C. Describes potential for enhancement to a higher state
- D. Made when not enough evidence supports the problem
Correct Answer: A
Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue.
Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.
Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson’s or Huntington’s diseases, or even epilepsy?
- A. Because clients suffer from depression, anxiety, and inability to perform basic self care
- B. Because clients become paralytic throughout the body
- C. Because the clients bone become weak, brittle, and painful to even move
- D. Because clients generally become very aggressive and violent with other people CARING FOR CLIENTS WITH NEUROLOGIC DEFICITS
Correct Answer: A
Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks.
Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.
To reduce symptoms of early morning stiffness in a ptient who has rheumatoid arthritis, the nurse can encourage the patient to:
- A. take a hot tub bath or shower in the morning
- B. put joints through passive ROM before tryoing to move them actively
- C. sleep with a hot pad
- D. take two aspirins before arising, and wait 15 minutes before attempting locomotion
Correct Answer: A
Rationale: The correct answer is A: take a hot tub bath or shower in the morning. This is effective as the warm water helps to relax muscles and joints, reducing stiffness. It also improves circulation, which can alleviate morning stiffness in patients with rheumatoid arthritis.
Incorrect choices:
B: Putting joints through passive ROM before active movement may exacerbate stiffness if not done properly.
C: Sleeping with a hot pad may provide temporary relief but does not address the root cause of morning stiffness.
D: Taking aspirin can help with pain but does not directly address stiffness. Waiting 15 minutes before moving may not be as effective as soaking in warm water.