Nokea
The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the ff. interventions is most important for the nurse to do before the procedure?
- A. Explain the procedure to the patient’s family
- B. Observe the patient for bleeding
- C. Administer an analgesic to the patient
- D. Drape the biopsy site
Correct Answer: B
Rationale: The correct answer is B: Observe the patient for bleeding. Before a bone marrow biopsy, it is crucial to monitor the patient for bleeding tendencies as the procedure can cause bleeding. This step ensures early detection and prompt intervention if bleeding occurs.
Explanation for other choices:
A: Explaining the procedure to the family is important for informed consent but not the most crucial before the procedure.
C: Administering an analgesic may be necessary for pain management but monitoring for bleeding takes precedence.
D: Draping the biopsy site is important for maintaining a sterile field but does not directly impact patient safety like monitoring for bleeding.
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A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
- A. States feels better after talking with family and friends
- B. Consumes high-carbohydrate foods when stressed
- C. Dislikes the support group meetings
- D. Spends most of the day in bed
Correct Answer: A
Rationale: The correct answer is A because stating feeling better after talking with family and friends demonstrates the use of healthy coping skills. This behavior indicates the patient is seeking and utilizing social support, which is crucial for managing stress and emotions effectively in diabetes management. Choices B, C, and D are incorrect because consuming high-carbohydrate foods when stressed can lead to poor blood sugar control, disliking support group meetings indicates avoidance of beneficial support resources, and spending most of the day in bed can contribute to physical and emotional deterioration, rather than effective coping.
Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?
- A. Hypocortisolism.
- B. Hyperglycemia
- C. Hypoglycemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Hypocortisolism. After a transsphenoidal hypophysectomy, the pituitary gland is removed or partially removed, leading to decreased cortisol production. Signs of hypocortisolism include weakness, fatigue, hypotension, weight loss, and electrolyte imbalances. Hyperglycemia (B) is not typically associated with this procedure. Hypoglycemia (C) is not a common concern post-hypophysectomy. Hypercalcemia (D) is not directly related to pituitary gland removal. Therefore, assessing for hypocortisolism is crucial for early detection and management post-surgery.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.” DISTURBANCES IN IMMUNOLOGIC FUNCTIONING
Correct Answer: E
Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
- A. Actinic
- B. Arcus
- C. Asymmetry
- D. Assessment
Correct Answer: C
Rationale: The correct answer is C: Asymmetry. The ABCD method is a mnemonic used for assessing skin lesions for possible skin cancer. The A in ABCD stands for Asymmetry, indicating that the lesion is not symmetrical in shape or color. Skin cancers often exhibit asymmetrical features. Actinic (Choice A) refers to sun damage, Arcus (Choice B) is a term related to the eye, and Assessment (Choice D) is a general term that does not specifically relate to skin lesion evaluation. By focusing on asymmetry, healthcare providers can identify potential skin cancer lesions early for further evaluation and treatment.
When teaching a preoperative older patient, which of the following is a technique to improve learning?
- A. Sit in front of window in bright sunlight.
- B. Speak in high tone.
- C. Use small, white-on-black printed
- D. Eliminate background noise. materials.
Correct Answer: D
Rationale: The correct answer is D, "Eliminate background noise." This technique is essential for older patients as they may have age-related hearing impairments. By reducing background noise, the patient can better focus on the information being conveyed. Sitting in bright sunlight (A) may cause glare and make it difficult to read or see clearly. Speaking in a high tone (B) may be perceived as aggressive or patronizing. Using small, white-on-black printed materials (C) may be challenging for older patients with visual impairments. Thus, eliminating background noise is the most effective technique to improve learning in preoperative older patients.