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A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
- A. Ask for at least two other assistive personnel to come to the room.
- B. Medicate the patient to alleviate discomfort while ambulating.
- C. Review the patient’s activity orders.
- D. Offer the patient a walker.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Safety: Morbidly obese patients are at higher risk of falls during transfers.
2. Assistance: Having two other personnel ensures safe transfer.
3. Weight distribution: Distributing the patient's weight among multiple helpers reduces strain.
4. Proper body mechanics: Allows for proper positioning and technique while assisting.
Summary of why other choices are incorrect:
B. Medication doesn't address the safety concern of transferring a morbidly obese patient.
C. Reviewing activity orders is not the immediate action needed for the patient's first bathroom transfer.
D. Offering a walker may not provide sufficient support for a morbidly obese patient during the transfer.
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A patient is scheduled for an MRI and asks what to expect. Which of the following responses by the nurse is best?
- A. “It is the measurement of muscle contraction after stimulation by tiny needle electrodes.”
- B. “Electrodes will be placed on your scalp to measure activity of the brain.”
- C. “A scan of the brain will be done after injection of radioisotope.”
- D. “It is a noninvasive test that uses magnetic energy to visualize internal parts.”
Correct Answer: D
Rationale: The correct answer is D because an MRI is a noninvasive imaging test that uses magnetic energy to produce detailed images of internal body parts. This explanation is accurate and informative, reassuring the patient.
A is incorrect because it describes electromyography (EMG), not MRI. B is incorrect as it describes electroencephalography (EEG), not MRI. C is incorrect because it describes a nuclear medicine test, not MRI. In summary, only option D provides a correct and relevant description of what to expect during an MRI.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
- A. The nurse provides assistance while the patient is walking in the hallways.
- B. The patient is able to ambulate in the hallway with crutches.
- C. The patient will deny pain while walking in the hallway.
- D. The patient’s level of mobility will improve.
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery.
A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
Which of the ff is a reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy?
- A. The adverse effect of mastectomy are immediate
- B. The wound of the surgery is highly contagious and the client should exercise isolation precautions immediately after the procedure
- C. Most clients are not hospitalized long after a mastectomy
- D. The suicidal tendencies in the women undergoing a mastectomy are high
Correct Answer: C
Rationale: Step 1: Most clients are not hospitalized long after a mastectomy - Correct. This is because mastectomy is often performed as an outpatient procedure, and clients are discharged home shortly after surgery.
Step 2: The adverse effects of mastectomy are not immediate - Incorrect. Adverse effects may occur post-surgery, but early discharge is not solely due to immediate adverse effects.
Step 3: The wound of the surgery is not highly contagious - Incorrect. Mastectomy wounds are not contagious, and isolation precautions are not necessary.
Step 4: Suicidal tendencies in women undergoing mastectomy are not high - Incorrect. While emotional support is crucial, early discharge is not primarily due to suicidal tendencies.
Summary: Choice C is correct because mastectomy clients are typically not hospitalized long, making early discharge instructions and home care arrangements necessary. Choices A, B, and D are incorrect as they do not directly relate to the primary reason for early discharge and home care planning.
During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived?
- A. The defining characteristics
- B. The related factors
- C. The problem statement
- D. The database
Correct Answer: C
Rationale: During outcome identification and planning, outcomes are derived from the problem statement of the nursing diagnoses. This is because the problem statement clearly defines the patient's health issue or condition that needs to be addressed, thus guiding the development of specific, measurable, and achievable outcomes. The defining characteristics (choice A) describe the signs and symptoms of the health problem but do not directly lead to outcome identification. The related factors (choice B) represent the potential causes or contributing factors to the health problem and are not used to derive outcomes. The database (choice D) consists of the patient's health history, assessment data, and laboratory findings, which are essential for diagnosing but do not directly determine outcomes. Therefore, the correct answer is C as it directly informs the outcomes to be achieved.