Nokea
A cheerful, elderly widow comes to the community clinic for her annual check-up. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, 'I don't get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing.' What is the priority nursing diagnosis?
- A. Social Interaction, Impaired related to perceived inability to interact
- B. Disturbed Sensory Perception related to progressive hearing loss
- C. Knowledge Deficit related to pathophysiological processes
- D. Coping, Ineffective related to change in sensory abilities
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select ONE that does not apply)
- A. Find an activity that you enjoy and will keep your hands busy.
- B. Make a list of reasons you want to stop smoking.
- C. Identify a punishment for yourself in case you backslide.
- D. Drink at least eight glasses of water each day.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A father asks you how to prevent another asthmatic attack in his son. You respond by
- A. Saying asthmatic attacks cannot be prevented.
- B. Asking his son's physician to change his medication.
- C. Instructing him to move his family immediately to a dry climate.
- D. Helping him identify triggers that cause asthmatic attacks and showing him how to avoid them.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What nursing order should be included in Mr. Puff’s care plan?
- A. Increase fluid intake to a minimum of 3000 ml/day
- B. Provide for postural drainage for 20 minutes after meals
- C. Restrict visitors
- D. Walk in hall t.i.d. for 20 minutes
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
It is important to teach a patient who is receiving immunosuppressive therapy for a bone marrow transplant to
- A. Avoid other people with signs of infection.
- B. Report signs of infection, such as sore throat or fever.
- C. Take the medications as directed.
- D. All of the above.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has received preoperative teaching for a vertical partial laryngectomy. The nurse determines that the teaching has been effective when the client states:
- A. I know I will need special swallowing training after my surgery.'
- B. The quality of my voice will be excellent after surgery.'
- C. I will have very little difficulty swallowing after surgery.'
- D. I may also have to have a radical neck dissection done.'
Correct Answer: C
Rationale: Special swallowing training is required for a client with a supraglottic (horizontal partial) laryngectomy, not a vertical partial laryngectomy. The quality of the client's voice will be altered, but it will be adequate for communication. The client will have minimal difficulty swallowing. A radical neck dissection may be done with a total laryngectomy, not with a partial laryngectomy.