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Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.
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The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
- A. Gordon’s Functional Health Patterns
- B. Activity-exercise pattern assessment
- C. General to specific assessment
- D. Problem-oriented assessment
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting the assessment by examining a specific aspect (surgical dressing with drainage) and will likely proceed to gather more detailed information based on the initial findings. This approach involves moving from a broad overview to specific details, which is essential in assessing postoperative patients for complications.
A: Gordon’s Functional Health Patterns is a comprehensive assessment framework that covers various aspects of an individual's health, not specifically focusing on the progression from general to specific assessments in this situation.
B: Activity-exercise pattern assessment focuses on the patient's activity levels and exercise routines, which is not the primary focus of the scenario described.
D: Problem-oriented assessment is a method that involves identifying and addressing specific health issues or concerns, which is not the primary aim of the assessment approach used by the nurse in this scenario.
Which of the ff is the primary sign of breast cancer?
- A. A bloody discharge from the nipple
- B. A retraction of the nipple
- C. A dimpling of the skin over the lesion
- D. A painless mass in the breast CLIENT IN BIOLOGICAL CRISIS MANAGEMENT of PATIENTS with COMPLICATIONS from HEART DISEASE
Correct Answer: D
Rationale: The correct answer is D: A painless mass in the breast. This is the primary sign of breast cancer because most breast cancers present as painless lumps or masses. This is due to the abnormal growth of cells forming a tumor. Other choices (A, B, C) are also signs of breast cancer, but they are not as common or primary as the presence of a painless mass. A bloody discharge from the nipple (A) can be a sign of a benign condition or cancer, but it is not the most common presentation. Nipple retraction (B) and dimpling of the skin over the lesion (C) can also be signs of breast cancer, but they usually occur in later stages of the disease. Therefore, the presence of a painless mass in the breast is the primary sign that should raise suspicion for breast cancer.
Which of the following dietary interventions prevents the precipitation of calcium renal stones?
- A. High fiber diet
- B. Increased protein intake
- C. High fluid intake
- D. Intake of zinc
Correct Answer: C
Rationale: The correct answer is C: High fluid intake. Adequate hydration helps prevent calcium from becoming concentrated in the urine, reducing the risk of calcium stone formation. Increased fiber intake (choice A) may help prevent other types of stones but not specifically calcium stones. Increased protein intake (choice B) can actually increase calcium excretion, potentially increasing the risk of calcium stone formation. Zinc intake (choice D) does not directly impact calcium stone formation. In summary, high fluid intake is crucial for preventing the precipitation of calcium renal stones due to its role in diluting urine and preventing calcium concentration.
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
- A. Gordon’s Functional Health Patterns
- B. Activity-exercise pattern assessment
- C. General to specific assessment
- D. Problem-oriented assessment
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing, which is a general observation, before moving on to more specific details. This approach allows the nurse to gather comprehensive information systematically.
A: Gordon’s Functional Health Patterns involves assessing a patient's health across several categories, not specifically related to wound care.
B: Activity-exercise pattern assessment focuses on the patient's physical activity and exercise routines, not the wound dressing.
D: Problem-oriented assessment involves identifying and addressing specific health issues, rather than starting with a general observation like the appearance of a surgical dressing.
When performing a neurological examination on Mr. RR, which of the following would not be considered an important or useful part of the examination?
- A. Eye movements
- B. Reflexes
- C. Nuchal rigidity
- D. Pupil size NEUROLOGIC MEDICATIONS
Correct Answer: D
Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.