Nokea
Which of the following nursing activities is an example of evaluation?
- A. Checking a client’s blood pressure 30 minutes after administering an antihypertensive medication
- B. Administering prescribed oxygen therapy to a client
- C. Developing a plan of care for a new client
- D. Teaching a client about low-sodium dietary options
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
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Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?
- A. To reduce the risk of seizures before and after surgery
- B. To avoid intraoperative complications
- C. To reduce cerebral edema
- D. To prevent postoperative vomiting
Correct Answer: A
Rationale: Step 1: Phenytoin is an anticonvulsant used to prevent seizures.
Step 2: Anticonvulsants are often given before surgery to reduce the risk of seizures during and after the procedure.
Step 3: In the context of intracranial surgery, controlling seizures is crucial to prevent complications like increased intracranial pressure.
Step 4: Therefore, administering phenytoin before surgery helps in reducing the risk of seizures before and after the procedure.
Summary:
- Option B (avoid intraoperative complications) is too broad and doesn't directly relate to the use of phenytoin.
- Option C (reduce cerebral edema) is not the primary indication for phenytoin in this scenario.
- Option D (prevent postoperative vomiting) is not a common reason for administering phenytoin before intracranial surgery.
Which finding is an early indicator of bladder cancer?
- A. Painless hematuria
- B. Nocturia
- C. Occasional polyuria
- D. Dysuria
Correct Answer: A
Rationale: The correct answer is A: Painless hematuria. This is an early indicator of bladder cancer because blood in the urine without pain is a common symptom in the early stages of the disease. Nocturia (B), frequent urination at night, is more commonly associated with urinary tract infections or benign prostatic hyperplasia. Occasional polyuria (C), excessive urination, can be a symptom of diabetes or kidney disease. Dysuria (D), painful urination, is more indicative of urinary tract infections or urethritis. Therefore, painless hematuria is the most specific early indicator of bladder cancer among the choices provided.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery.
Incorrect choices:
B: Hiccups - Hiccups are not a common side effect of Ketamine administration.
C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions.
D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids.
Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment?
- A. Carrying out a physician’s order to intubate a client
- B. Educating a novice nurse on the principles of triage
- C. Using the nursing process to diagnose a blocked airway
- D. Interviewing privately a client suspected of being a victim of abuse
Correct Answer: D
Rationale: The correct answer is D because interviewing a client suspected of being a victim of abuse involves critical thinking in assessment by gathering relevant information, analyzing the situation, and making informed decisions. This activity helps identify potential risks and ensures the client's safety. On the other hand, options A and C involve implementing orders and diagnosing conditions, respectively, which are more related to clinical decision-making rather than assessment. Option B focuses on education, which is not directly linked to assessment activities.
Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Positive reinforcement helps enhance communication skills in individuals with expressive aphasia.
2. Providing positive feedback when Mr. Reyea uses words correctly encourages him to continue trying to communicate.
3. It boosts his confidence and motivation, leading to improved verbal communication over time.
Summary of why other choices are incorrect:
B. Waiting indefinitely for Mr. Reyea to verbally state his needs may lead to frustration and hinder effective communication.
C. Suggesting permanent help at home assumes Mr. Reyea's condition cannot improve, which is not necessarily true for expressive aphasia.
D. Helping the family accept Mr. Reyea's communication challenges does not actively support his communication improvement and may limit his progress.