Nokea
A client has been scheduled for a Schilling test. What instruction will the nurse give the client?
- A. Take nothing mouth fro 12 hours prior to the test
- B. Collect his urine for 12 hours
- C. Administer a fleet enema the evening before the test
- D. Empty his bladder immediately before the test
Correct Answer: B
Rationale: The correct answer is B: Collect his urine for 12 hours. This instruction is given because the Schilling test involves collecting urine over a specific time period to measure the absorption of vitamin B12. A is incorrect because fasting is not necessary. C is incorrect as enema is not required. D is incorrect as emptying the bladder is not part of the test procedure.
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A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. This ensures patient-centered care and respects the patient's autonomy. Speaking only to the daughter may undermine the patient's dignity and may lead to incomplete information gathering. Choices A, C, and D are incorrect as they are appropriate nursing communication techniques that facilitate rapport-building and active listening with the patient. Making eye contact, leaning forward, and nodding are all positive non-verbal cues that show engagement and attentiveness to the patient, promoting effective communication and building trust.
In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?
- A. Etiology
- B. Problem
- C. Defining characteristics
- D. Client need
Correct Answer: A
Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors that lead to the identified problem. In this case, the presence of a large scar over the left side of the face is the underlying cause of the disturbed self-esteem. It directly influences the client's self-perception and self-worth. The problem (B) is the disturbed self-esteem itself, not the scar. Defining characteristics (C) are the signs and symptoms that support the nursing diagnosis. Client need (D) is a broader concept that encompasses the overall needs of the client, whereas etiology specifically focuses on the cause of the problem.
Miss OB’s malignant tumor in her left breast was discovered to be spreading all over the surrounding and adjacent tissue and not entering the blood stream, it would be:
- A. Malignant
- B. Non-malignant
- C. Benign
- D. B and C
Correct Answer: A
Rationale: The correct answer is A: Malignant. A malignant tumor spreading to surrounding tissues indicates invasive growth, characteristic of malignancy. It is aggressive and can invade nearby structures. Non-malignant tumors are localized and do not invade surrounding tissues. Benign tumors are non-invasive and do not spread to other parts of the body. Choice D is incorrect because a tumor spreading to surrounding tissues is indicative of malignancy, not benignity.
A client with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U- 100 regular insulin and 35 U of 100-U isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
- A. “Inject insulin into healthy tissue with large blood vessels and nerves.”
- B. “Rotate injection sites within the same anatomic region, not among different regions.”
- C. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
- D. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”
Correct Answer: B
Rationale: The correct answer is B: “Rotate injection sites within the same anatomic region, not among different regions.” This instruction is important to prevent lipodystrophy and ensure consistent insulin absorption. Rotating sites within the same region helps maintain consistent insulin absorption rates and reduces the risk of developing scar tissue or fatty deposits. Injecting into healthy tissue with large blood vessels and nerves (choice A) can lead to inconsistent absorption. Administering insulin into areas of scar tissue or hypotrophy (choice C) can also disrupt absorption. Injecting into sites above muscles planned for exercise (choice D) can lead to unpredictable insulin absorption. Rotation within the same region optimizes insulin delivery and prevents complications.
Which of the following is an appropriate nursing intervention to prevent infection in patients with AIDS?
- A. Prohibiting patients who are severely immunodeficient from having any visitors.
- B. Prohibiting visitors with a cough.
- C. Wearing protective gear such as gown, mask, gloves, and goggles when entering the room.
- D. Ensuring protective barrier isolation precautions are in place.
Correct Answer: C
Rationale: The correct answer is C. Wearing protective gear such as gown, mask, gloves, and goggles when entering the room is crucial to prevent infection in patients with AIDS. This intervention helps to minimize the risk of transmitting pathogens to the patient and vice versa. The protective gear acts as a barrier to prevent the spread of infectious agents. It also protects healthcare workers from exposure to potentially harmful pathogens.
Prohibiting visitors who are severely immunodeficient (choice A) may be isolating for the patient and does not directly address preventing infection transmission. Prohibiting visitors with a cough (choice B) is important but does not cover all potential sources of infection. Ensuring protective barrier isolation precautions are in place (choice D) is a general statement and does not specify the practical steps needed to prevent infection transmission effectively.