Nokea
A client who is HIV positive should have the mouth examined for which oral problem common associated with AIDS?
- A. Halitosis
- B. Creamy white patches
- C. Carious teeth
- D. Swollen lips
Correct Answer: B
Rationale: The correct answer is B: Creamy white patches. These patches are indicative of oral thrush, a common fungal infection seen in individuals with weakened immune systems like those with AIDS. This infection is caused by Candida albicans. It presents as white patches on the tongue, inner cheeks, or roof of the mouth. Halitosis (A) is bad breath, not specific to AIDS. Carious teeth (C) refers to cavities, not directly related to AIDS. Swollen lips (D) can be a symptom of various oral conditions, but not specific to AIDS. In summary, creamy white patches are a characteristic oral problem associated with AIDS due to opportunistic infections like oral thrush.
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An adult has a central line in his right subclavian vein. The nurse is to change the tubing. Which of the following should be done?
- A. Use the present solution with the new tubing
- B. Connect the new tubing to the hub prior to running any fluid through the tubing
- C. Close the roller clamp on the new tubing after priming it
- D. Have the client roll to the right side to prevent an air embolus
Correct Answer: C
Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.
In addition to antibiotics, which of the ff. recommendations can the nurse make to increase comfort in a patient experiencing sinusitis? Choose all answers that are correct. i. Coughing and deep breathing iv. Room humidifier ii. Sinus irrigation v. Percussion and postural drainage iii. Hot moist packs vi. Semi-fowler’s position
- A. 1 ,2 and 5
- B. 1, 3, 4 and 5
- C. 3, 4 and 6
- D. 2, 4, 5 and 6
Correct Answer: D
Rationale: The correct answer is D: 2, 4, 5, and 6.
1. Room humidifier (choice 2) helps to keep the air moist, which can ease sinus pressure and discomfort.
2. Hot moist packs (choice 4) can provide relief by reducing congestion and promoting sinus drainage.
3. Percussion and postural drainage (choice 5) can help loosen mucus and improve drainage.
4. Semi-fowler's position (choice 6) can also aid in drainage and reduce sinus pressure.
Choices A, B, and C are incorrect because they do not include all the recommended interventions that can help increase comfort in a patient with sinusitis. Each of the incorrect choices is missing at least one crucial recommendation that is beneficial for managing sinusitis symptoms.
Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: The correct answer is A. When someone is extremely confused, providing new information slowly and in small amounts can help prevent overwhelming stress and further confusion. This approach allows the individual to process information more effectively and reduces the risk of escalating confusion or delirium as a defense mechanism. Choices B, C, and D are incorrect because destruction of brain cells, teaching progression, and giving minimal information are not directly related to managing confusion in this scenario.
A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client’s signs/symptoms is:
- A. fluid volume deficit related to depletion of intravascular volume
- B. altered thought process related to toxic effects of elevated ammonia levels
- C. abdominal pain related to increased intestinal peristalsis
- D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A
Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
- A. “Choose all the interventions and perform them in order of time needed for each one.”
- B. “Make sure you identify the scientific rationale for each intervention first.”
- C. “Decide on goals and outcomes you have chosen for the patients.”
- D. “Begin with the highest priority diagnoses, then select appropriate interventions.”
Correct Answer: D
Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions."
Rationale:
1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being.
2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery.
3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient.
4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes.
Summary:
A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs.
B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses.
C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.