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Why does the nurse instruct the client to avoid Valsalva maneuvers?
- A. Clients BP will decrease momentarily
- B. Client may lose consciousness
- C. Client may suffer from a myocardial
- D. Clients BP will increase momentarily infarction
Correct Answer: B
Rationale: The correct answer is B because performing Valsalva maneuver can lead to a sudden drop in blood pressure, causing the client to lose consciousness. This occurs due to the increased intra-abdominal pressure leading to decreased venous return to the heart. Choices A, C, and D are incorrect as they do not accurately reflect the consequences of Valsalva maneuver. Option A stating that the client's blood pressure will decrease momentarily is incorrect as it actually increases initially. Option C suggesting that the client may suffer from a myocardial infarction is incorrect as Valsalva maneuver does not directly cause heart attacks. Option D implying that the client's blood pressure will increase momentarily is also incorrect as the immediate effect is a rise followed by a significant drop.
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Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
- A. Sore throat
- B. Acute pain
- C. Sleep apnea
- D. Heart failure
Correct Answer: B
Rationale: The correct answer is B: Acute pain. The NANDA-I (North American Nursing Diagnosis Association International) approved diagnosis must meet specific criteria related to patient assessment data, defining characteristics, and related factors. Acute pain is a well-defined nursing diagnosis with specific defining characteristics and related factors, making it a suitable and approved option for inclusion in a patient's care plan. Sore throat, sleep apnea, and heart failure do not meet the criteria for a NANDA-I approved diagnosis as they lack the specificity and comprehensive assessment data required for a nursing diagnosis.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: The correct answer is C because it is essential for the nurse to ensure accurate and up-to-date vital signs before administering medications. By asking the NAP to record the patient's vital signs, the nurse can make informed decisions about the patient's condition and prevent any potential complications.
Choice A is incorrect because administering medications without knowing the patient's vital signs, particularly if they are abnormal, can be dangerous. Choice B is not the best course of action as it delays the crucial step of obtaining the vital signs. Choice D is incorrect as omitting vital signs without assessment could compromise patient safety. Therefore, choice C is the most appropriate response to ensure patient well-being and medication safety.
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
- A. Cancerous lumps.
- B. Changes from previous self-examinations.
- C. Areas of thickness or fullness.
- D. Fibrocystic masses.
Correct Answer: A
Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
- A. Sore throat
- B. Acute pain
- C. Sleep apnea
- D. Heart failure
Correct Answer: B
Rationale: The correct answer is B: Acute pain. The rationale is that NANDA-I (North American Nursing Diagnosis Association-International) approves nursing diagnoses that are specific, measurable, and relevant to nursing care. Acute pain fits these criteria as it is a common nursing diagnosis that can be assessed objectively and treated with nursing interventions. The other choices (sore throat, sleep apnea, heart failure) are medical diagnoses that do not fall under the scope of nursing diagnoses approved by NANDA-I. Therefore, acute pain is the most appropriate diagnosis to be documented in a patient's care plan according to NANDA-I guidelines.
A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
- A. Risk for impaired physical mobility due to surgery
- B. Ineffective denial related to poor coping mechanisms
- C. Disturbed body image related to the incision scar
- D. Risk of injury related to surgical outcomes
Correct Answer: C
Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance.
A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery.
B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client.
D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.