Nokea
A 70-year old male diagnosed with BPH (benign prostatic hyperplasia) asks the nurse about his disease. The best response would be:
- A. “It an be caused by chronic infection of the urinary tract.”
- B. “It was caused by your chronic cigarette smoking.”
- C. “As you age, hormonal imbalances are the more likey cause of your disease.”
- D. “Chronic obstruction of the bladder due to stone can cause BPH.”
Correct Answer: C
Rationale: The correct answer is C. Hormonal imbalances are the primary cause of BPH in aging males. As men age, testosterone levels decrease and estrogen levels may increase relative to testosterone, leading to prostate gland growth. This is why hormonal imbalances are more likely the cause of BPH in older males.
Explanation of other choices:
A: Chronic infection of the urinary tract does not directly cause BPH, although it can lead to similar symptoms such as urinary frequency and urgency.
B: Chronic cigarette smoking is not a direct cause of BPH, although it can contribute to overall prostate health and exacerbate symptoms.
D: Chronic obstruction of the bladder due to stone is a separate condition from BPH, although it can cause similar urinary symptoms.
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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.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: The correct answer is C because respiratory rate is an observable and measurable data point, making it objective. Objective data is factual and observable, such as vital signs. Choices A, B, and D are subjective data as they rely on the patient's perception or interpretation, which can be influenced by various factors and may not always be accurate or reliable. In this case, the nurse can directly measure and document the patient's respiratory rate, making it an objective piece of information.
A patient’s serum sodium is within normal range. The nurse estimates that serum osmolality should be:
- A. Less than 136mOsm/kg
- B. Greater than 408mOsm/kg
- C. 280 to 295mOsm/kg
- D. 350 to 544mOsm/kg
Correct Answer: C
Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
- A. Is written as a two-part statement
- B. Describes human response to a health problem
- C. Describes potential for enhancement to a higher state
- D. Made when not enough evidence supports the problem
Correct Answer: A
Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?
- A. The client is maintained on strict bed rest
- B. The head of the bed is at 30-degree angle
- C. The client receives a complete bed bath each morning
- D. The nurse checks the applicator’s position every 4 hours
Correct Answer: B
Rationale: The correct answer is B because having the head of the bed at a 30-degree angle can cause the radioactive material to shift, potentially leading to an uneven distribution of radiation. This could result in harmful exposure to surrounding tissues.
A: Maintaining the client on strict bed rest is important to prevent displacement of the radioactive applicator.
C: Providing a complete bed bath each morning is necessary for hygiene and does not pose a radiation hazard.
D: Checking the applicator's position every 4 hours is essential to ensure proper placement and does not indicate a radiation hazard.