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A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?
- A. Risk for impaired skin integrity
- B. Imbalanced nutrition: Risk for more than
- C. Constipation body requirements
- D. Ineffective thermoregulation
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. Myocardial infarction, hypertension, and progressive systemic sclerosis can lead to impaired circulation and skin breakdown. Clients with these conditions are at risk for pressure ulcers due to decreased blood flow and compromised skin integrity. The other options, B: Imbalanced nutrition, C: Constipation, and D: Ineffective thermoregulation, do not directly relate to the client's conditions or the potential complications associated with them. Therefore, the most appropriate nursing diagnosis for this client would be A: Risk for impaired skin integrity.
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The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
- A. Administer the acetaminophen.
- B. Notify the health care provider to obtain a verbal order.
- C. Direct the nursing assistive personnel to give the acetaminophen.
- D. Perform a pain assessment only after administering the acetaminophen.
Correct Answer: A
Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows:
1. The patient has a standing order for acetaminjson for headache relief.
2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours.
3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs.
Summary:
- Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order.
- Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision.
- Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
- A. A decreased serum creatinine level.
- B. Bence jones protein in the urine.
- C. Hypocalcemia.
- D. A low serum protein level.
Correct Answer: B
Rationale: The correct answer is B: Bence jones protein in the urine. In multiple myeloma, abnormal plasma cells produce excess monoclonal immunoglobulins, including Bence Jones proteins, which can be detected in the urine. This is a hallmark finding in multiple myeloma diagnosis.
A: Incorrect. Serum creatinine levels are typically not affected in multiple myeloma.
C: Incorrect. Hypercalcemia, not hypocalcemia, is commonly seen in multiple myeloma due to bone destruction.
D: Incorrect. Multiple myeloma often presents with high serum protein levels, not low levels.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This is the most appropriate nursing diagnosis for a patient with pneumonia and lower lobe infiltrates. The rationale is that pneumonia causes inflammation and fluid accumulation in the alveoli, impairing the exchange of oxygen and carbon dioxide in the lungs. This directly affects gas exchange.
Choice A is incorrect because ineffective breathing pattern is a broad nursing diagnosis that does not specifically address the underlying issue of impaired gas exchange in pneumonia. Choice B is incorrect as the risk of infection related to the chest x-ray procedure is unrelated to the patient's current condition of pneumonia. Choice C is also incorrect as dehydration does not directly correlate with the patient's diagnosis of pneumonia and lower lobe infiltrates.
Nurse Carlos teaches a community adult class about the common symptoms of tuberculosis. Which of the following should Nurse Carlos include?
- A. weight loss
- B. dyspnea on exertion
- C. increased appetite
- D. mental status changes
Correct Answer: A
Rationale: The correct answer is A: weight loss. Weight loss is a common symptom of tuberculosis due to the impact of the infection on the body's metabolism and appetite. This symptom is important to recognize as it can be an early indicator of the disease. Dyspnea on exertion (B) is not a common symptom of tuberculosis, as it typically affects the lungs rather than causing difficulty breathing. Increased appetite (C) is not a typical symptom, as TB usually leads to decreased appetite and weight loss. Mental status changes (D) are not directly associated with tuberculosis and are more commonly seen in other conditions affecting the brain. Therefore, weight loss is the most relevant symptom to include in the teaching material for identifying possible cases of tuberculosis.
For a client with polycythemia vera, how can the nurse help decrease the risk for thrombus formation?
- A. Teach the client how to perform isometric exercises
- B. Help the client don thromboembolic stocking or support hose during waking hours
- C. Advise drinking 3 quarts (L) of fluid per day
- D. Instruct the client to rest immediately if chest pain develops A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET I THE HEMATOLOGIC SYSTEM
Correct Answer: B
Rationale: The correct answer is B: Help the client don thromboembolic stocking or support hose during waking hours. This intervention helps decrease the risk for thrombus formation in polycythemia vera by promoting venous return and preventing blood pooling in the lower extremities. Compression stockings improve circulation and reduce the risk of blood clots. Isometric exercises (choice A) may increase blood pressure and heart rate, potentially worsening the risk of thrombus formation. Drinking excess fluid (choice C) can lead to hypervolemia and increase the risk of clotting. Resting immediately if chest pain develops (choice D) is important but does not directly address the prevention of thrombus formation in polycythemia vera.