Nokea
A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?
- A. I have assessed you and find you are fatigued.
- B. I analyzed and interpreted your information as fatigue.
- C. Why are you so tired all the time?
- D. I think fatigue is a problem for you. Do you agree?
Correct Answer: D
Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.
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A client is receiving chemotherapy for cancer. The nurse reviews the client’s laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
- A. Activity intolerance
- B. Impaired tissue integrity
- C. Impaired oral mucous membranes
- D. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Correct Answer: D
Rationale: The correct answer is D: Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Thrombocytopenia is a low platelet count, which can lead to impaired blood clotting and potential bleeding. Ineffective tissue perfusion is the most critical concern as it can lead to life-threatening complications like hemorrhage. Activity intolerance, impaired tissue integrity, and impaired oral mucous membranes are important but do not pose an immediate threat to the client's life compared to the risk of hemorrhage from thrombocytopenia.
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
- A. “Administer desmopressin while the suspension is cold.”
- B. “Your condition isn’t chronic, so you won’t need to wear a medical identification bracelet.”
- C. “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”
- D. “You won’t need to monitor your fluid intake and output after you start taking desmopressin.”
Correct Answer: C
Rationale: The correct answer is C: “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”
Rationale:
1. Desmopressin is available in intranasal form for diabetes insipidus.
2. Nasal discharge or blockage may prevent proper absorption of the medication.
3. Instructing the client about this potential issue ensures optimal drug effectiveness.
Summary:
A: Incorrect. Temperature of desmopressin suspension doesn't affect its efficacy.
B: Incorrect. A medical identification bracelet is necessary for chronic conditions like diabetes insipidus.
D: Incorrect. Monitoring fluid intake and output is crucial when taking desmopressin.
Which of the following medications should then nurse explain may cause headache as a side effect?
- A. Furosemide (Lasix)
- B. Clonidine (Catapres)
- C. Atenolol ((Tenormin)
- D. Adalat (Procardia)
Correct Answer: B
Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.
Which of the following procedures does the nurse understand is used to correct otosclerosis?
- A. Myringotomy
- B. Mastoidectomy
- C. Myringoplasty
- D. Stapedectomy
Correct Answer: D
Rationale: The correct answer is D: Stapedectomy. This procedure is used to correct otosclerosis by removing the stapes bone and replacing it with a prosthetic device. This restores normal hearing by allowing sound waves to travel through the ear properly. Myringotomy (A) is a procedure to drain fluid from the middle ear, not to correct otosclerosis. Mastoidectomy (B) is the removal of infected mastoid air cells, not related to otosclerosis. Myringoplasty (C) is a surgical procedure to repair a perforated eardrum, not used for otosclerosis. Stapedectomy is the most appropriate choice for correcting otosclerosis as it directly addresses the abnormal bone growth in the middle ear.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: B
Rationale: The correct answer is B: Expressive aphasia and paralysis on the left side of the body. In a right-handed person, the left side of the brain controls language (Broca's area) and motor function for the right side of the body. A stroke affecting the left side of the cortex would lead to expressive aphasia (difficulty speaking) due to damage to Broca's area and paralysis on the right side of the body due to motor function impairment. Choices A, C, and D are incorrect because they do not align with the known neurological functions of the brain regions affected by the stroke.