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A 17-year-old student enters the emergency department with a nosebleed that won’t quit. Which of the following positions is recommended for the patient with a nosebleed?
- A. Lying down with feet elevated
- B. Sitting up with neck extended
- C. Lying down with a small pillow under the head
- D. Sitting up leaning slightly forward
Correct Answer: D
Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.
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A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse document?
- A. Decreased cardiac output related to altered myocardial contractility.
- B. Patient needs a low-fat diet related to inadequate heart perfusion. NursingStoreRN
- C. Offer a low-fat diet because of heart problems.
- D. Acute heart pain related to discomfort.
Correct Answer: A
Rationale: The correct answer is A because it follows the correct format of a nursing diagnosis: "Problem related to Etiology." In this case, "Decreased cardiac output" is the problem, and "altered myocardial contractility" is the cause. This format helps identify the specific issue and its underlying cause, allowing for targeted interventions. Choice B is incorrect as it doesn't follow the problem-etiology format and lacks specificity. Choice C is also incorrect as it lacks a clear nursing diagnosis and specific etiology. Choice D is incorrect as it presents a symptom rather than a nursing diagnosis with an associated cause. Overall, choice A is the best option as it provides a clear, specific nursing diagnosis that guides appropriate nursing interventions.
Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: The correct answer is C because washing feet in hot water can lead to burns or skin damage for those with diabetes. A: Proper footwear is essential for preventing foot injuries. B: Trimming toenails straight across helps prevent ingrown nails. D: Wearing shoes on hot surfaces prevents burns or blisters. Overall, C is incorrect due to the potential harm it can cause to diabetic feet.
A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg PO daily. Which finding should the nurse recognize as an adverse effect?
- A. Dysuria
- B. Tachycardia
- C. Leg cramps
- D. Blurred vision
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. Levothyroxine is a synthetic form of thyroid hormone used to treat hypothyroidism. If the dose is too high, it can lead to symptoms of hyperthyroidism, including tachycardia (rapid heartbeat). This is because an excess of thyroid hormone can increase the heart rate. Dysuria (choice A) is not a common adverse effect of levothyroxine. Leg cramps (choice C) are more commonly associated with electrolyte imbalances. Blurred vision (choice D) is not a typical adverse effect of levothyroxine.
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.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: The correct answer is A: Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. This is because regular screening with both tests can help detect prostate cancer early. The digital rectal exam allows the doctor to feel for any abnormalities in the prostate gland, while the PSA test measures the levels of a specific protein produced by the prostate gland. If there are any concerning findings, further diagnostic tests can be done to confirm prostate cancer.
Choice B is incorrect because transrectal ultrasound is not a recommended screening test for prostate cancer. Choice C is incorrect as testicular self-examinations are for detecting testicular cancer, not prostate cancer. Choice D is incorrect as CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.