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A 25-year old with hepatitis may be anicteric and symptomless. In the early part of the hepatic inflammatory disorder, the most likely symptom/sign is:
- A. dark urine
- B. occult blood in stools
- C. ascites
- D. anorexia
Correct Answer: D
Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.
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Monthly examination (BSE) can help in early detection of breast CA. When do you perform BSE?
- A. once a month after menstruation
- B. every ether month after menstruation
- C. once a month before menstruation
- D. every other month before menstruation
Correct Answer: A
Rationale: The correct answer is A: once a month after menstruation. Performing BSE at this time helps ensure consistent examination when breasts are less tender or swollen, making it easier to detect abnormalities. Performing it once a month ensures regular monitoring for any changes. Choices B, C, and D are incorrect because they do not provide the recommended frequency or timing for an effective BSE. BSE should be done monthly after menstruation to increase the chances of early detection of breast cancer.
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
- A. Set priorities for patient care.
- B. Determine whether outcomes or standards are met.
- C. Ambulate patient 25 feet in the hallway.
- D. Document results of goal achievement.
Correct Answer: A
Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.
Clinical manifestations of Huntington’s disease include:
- A. Abnormal involuntary movements (chorea)
- B. Intellectual decline
- C. Emotional disturbances
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is a hallmark feature of Huntington's disease, caused by damage to the basal ganglia. Intellectual decline includes cognitive impairments such as memory loss and executive dysfunction. Emotional disturbances involve mood swings, irritability, and apathy. Therefore, all three manifestations are commonly seen in individuals with Huntington's disease, making D the correct choice. Choices A, B, and C are incorrect individually because they do not encompass all the key clinical features of Huntington's disease.
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
- A. Scalp
- B. Chest
- C. Axillae
- D. Conjunctivae
Correct Answer: D
Rationale: The correct answer is D: Conjunctivae. Pallor is best assessed in the conjunctivae due to the transparent nature of the tissue, allowing for easy observation of paleness. The conjunctivae are the mucous membranes lining the inner surface of the eyelids and covering the sclera. Anemia can cause decreased hemoglobin levels, resulting in paleness of the mucous membranes. Assessing the scalp (A), chest (B), or axillae (C) may not provide a clear indication of pallor related to anemia. The conjunctivae offer a direct and reliable site to assess for pallor in patients with anemia.
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards?
- A. Professional physicians’ organizations
- B. State Nurse Practice Acts
- C. The Joint Commission
- D. The Agency for Health Care Research and Quality
Correct Answer: B
Rationale: Correct Answer: B (State Nurse Practice Acts)
Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care.
Summary of Incorrect Choices:
A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice.
C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice.
D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.