Nokea
A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?
- A. Provide respiratory support.
- B. Place the client in droplet isolation.
- C. Administer antihypertensive medications.
- D. Monitor ascites.
Correct Answer: A
Rationale: Step 1: Inhalation anthrax causes severe respiratory distress.
Step 2: Providing respiratory support helps maintain oxygenation.
Step 3: Oxygen therapy or mechanical ventilation may be needed.
Step 4: This choice directly addresses the critical needs of the client.
Summary:
- B: Droplet isolation is not needed as anthrax is not transmitted person-to-person.
- C: Antihypertensive medications are irrelevant to inhalation anthrax treatment.
- D: Ascites monitoring is not a priority in late-stage inhalation anthrax.
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Steve, who is diagnosed with pneumonia following recent intrathoracic surgery, will likely be prescribed
- A. Cephalosporin, such as cefazolin.
- B. Penicillin, such as amoxicillin.
- C. Fluoroquinolone, such as levofloxacin.
- D. Tetracycline, such as doxycycline.
Correct Answer: A
Rationale: Cephalosporins are commonly used antibiotics for treating post-surgical pneumonia.
If a client denies having a hearing impairment, which question would encourage them to respond?
- A. Do you always ask people to repeat questions? If so, do you think that you have a hearing problem?
- B. Are you cupping your ear for a reason? Do you have trouble hearing?
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Asking open-ended questions increases the likelihood of acknowledgment and discussion of the issue.
Yesterday, a male client had a transurethral resection of the prostate (TURP). Today, the client is concerned about the small amount of blood found in his urine. The nurse should explain to the client that the blood:
- A. should not be there on the second day.
- B. will stop when the Foley catheter is removed.
- C. is normal and he should not be concerned.
- D. can be removed by irrigating the bladder.
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. The client will continue to have a small amount of hematuria even after the Foley catheter is removed. Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. Irrigating the bladder will not remove the hematuria. Irrigation is performed to remove blood clots and to facilitate urinary drainage.
List and briefly describe the five dimensions of pain.
- A. Biological dimension: Physiological aspects of pain
- B. Behavioral dimension: Observable responses to pain
- C. Cognitive dimension: Thought processes related to pain
- D. Emotional dimension: Psychological reactions to pain
Correct Answer: A
Rationale: The correct answer includes all five dimensions: biological, behavioral, cognitive, emotional, and sociocultural.
A hospitalized Native American patient tells the nurse that later in the day a medicine man from his tribe is coming to perform a healing ceremony to return his world to balance. What should the nurse recognize about this situation?
- A. The patient does not adhere to an organized,formal religion.
- B. The patient’s spiritual needs may be met by traditional rituals.
- C. The patient’s spiritual needs may be met by traditional rituals.
- D. The patient may be putting his health in jeopardy by relying on rituals.
Correct Answer: B
Rationale: Traditional rituals such as those performed by a medicine man can meet the spiritual needs of Native American patients. This approach respects their cultural beliefs without undermining conventional medical treatment.