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A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
- A. “I’ll play card games with my friends.”
- B. “I’ll take a long trip to visit my aunt.”
- C. “I’ll bowl with my team after discharge.”
- D. “I’ll eat lunch in a restaurant everyday.”
Correct Answer: C
Rationale: The correct answer is C because bowling with the team after discharge promotes social interaction and physical activity, addressing both the diversional activity deficit and the decreased energy. Playing card games (A) may not involve physical activity. Taking a long trip (B) may be overwhelming and tiring. Eating in a restaurant daily (D) does not address the need for meaningful activities or social interaction.
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Which of the following is the appropriate nursing diagnosis?
- A. Fluid volume deficit R/T furrow tongue
- B. Fluid volume deficit R/T uncontrolled vomiting
- C. Dehydration R/T subnormal body temperature
- D. Dehydration R/T incessant vomiting
Correct Answer: B
Rationale: The correct answer is B, "Fluid volume deficit R/T uncontrolled vomiting." This option correctly identifies the cause of the fluid volume deficit as uncontrolled vomiting, which is a common reason for fluid loss. The nursing diagnosis should always reflect the underlying cause of the issue.
A is incorrect as "furrow tongue" is not a recognized medical term related to fluid volume deficit.
C is incorrect because dehydration is not typically related to subnormal body temperature unless it is severe.
D is incorrect as incessant vomiting is more specific to the cause, but the term "dehydration" should be used instead of "fluid volume deficit" in this context.
In summary, option B is the appropriate nursing diagnosis as it accurately links the fluid volume deficit to the cause of uncontrolled vomiting.
One of the dangers of treating hypernatremia is:
- A. Red blood cell crenation
- B. Cerebral edema
- C. Red blood cell hydrolysis
- D. Renal shutdown
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications.
Incorrect choices:
A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia.
C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis.
D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.
After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?
- A. Auscultation of the lungs
- B. Complaint of nausea
- C. Sensation of burning in her epigastric area
- D. Belief that demons are in her stomach
Correct Answer: A
Rationale: The correct answer is A because auscultation of the lungs involves direct observation and measurement, making it objective data. This data is based on what the nurse hears through the stethoscope, which can be verified and measured. Choices B, C, and D involve subjective experiences or interpretations that cannot be directly observed or measured. Complaint of nausea, sensation of burning, and belief in demons are all based on the client's feelings, perceptions, or beliefs, which are subjective and can vary from person to person. Objective data is factual, measurable, and observable, making choice A the correct answer in this scenario.
A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
- A. Patient will have one soft, formed bowel movement by end of shift.
- B. Patient will walk unassisted to bathroom by the end of shift.
- C. Patient will be offered laxatives or stool softeners this shift.
- D. Patient will not take any pain medications this shift.
Correct Answer: A
Rationale: The correct answer is A. The most appropriate outcome for the nurse to include in the plan of care is for the patient to have one soft, formed bowel movement by the end of the shift. This outcome directly addresses the nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. By aiming for a soft, formed bowel movement, the nurse is working towards alleviating the constipation issue caused by the pain medications. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART), making it an appropriate goal for the patient's care plan.
Choice B is incorrect because walking unassisted to the bathroom does not directly address the constipation issue. Choice C is incorrect as offering laxatives or stool softeners is a nursing intervention and not an outcome. Choice D is incorrect as withholding pain medications may not be in the best interest of the patient's overall care and does not directly target the constipation issue.
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
- A. Affected area appears to enlarge
- B. Red streaks extend up the arm or leg
- C. Additional lymph nodes become
- D. Liver and spleen become enlarged
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Lymphangitis is an inflammation of lymphatic vessels.
2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection.
3. Nurse should notify the physician for further evaluation and treatment.
4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification.
5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification.
6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.