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A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a client with a cerebellar brain tumor may experience impaired balance due to the cerebellum's role in coordinating voluntary movements and maintaining balance. Impaired balance increases the risk for falls and other injuries. Visual field deficits, difficulty swallowing, and psychomotor seizures are not directly related to the cerebellum's functions in balance and coordination. Therefore, these choices are incorrect for this specific nursing diagnosis.
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Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: The correct answer is D because it offers the patient autonomy by providing a choice between brushing their teeth independently or having assistance. This empowers the patient to make decisions regarding their personal hygiene, promoting independence and self-esteem. Choice A does not offer a choice or empower the patient. Choice B focuses solely on the location of the toothbrush and does not address the patient's needs. Choice C does not provide the patient with a sense of control over their hygiene routine. By contrast, choice D acknowledges the patient's needs, offers a choice, and encourages independence.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D because asking the patient about their usual sleep patterns and onset of difficulty resting is crucial to understand the situation fully. This helps to identify any potential underlying issues contributing to the sleep disturbance. Choice A is incorrect as it dismisses the patient's concerns. Choice B is not as effective as directly addressing the patient's sleep issues. Choice C delays the assessment, potentially missing important information. By choosing answer D, the nurse can gather valuable information to address the patient's sleep problem effectively.
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment?
- A. Carrying out a physician’s order to intubate a client
- B. Educating a novice nurse on the principles of triage
- C. Using the nursing process to diagnose a blocked airway
- D. Interviewing privately a client suspected of being a victim of abuse
Correct Answer: D
Rationale: The correct answer is D because interviewing a client suspected of being a victim of abuse involves critical thinking in assessment by gathering relevant information, analyzing the situation, and making informed decisions. This activity helps identify potential risks and ensures the client's safety. On the other hand, options A and C involve implementing orders and diagnosing conditions, respectively, which are more related to clinical decision-making rather than assessment. Option B focuses on education, which is not directly linked to assessment activities.
A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
- A. 4.0mEq/L
- B. 2.0mEq/L
- C. 8.0mE⁺q/L
- D. 2.6mEq/L
Correct Answer: B
Rationale: The correct answer is B: 2.0mEq/L. Severe vomiting can lead to hypokalemia, characterized by flat T waves and ST segment depression on ECG. This is due to decreased potassium levels affecting cardiac repolarization. A potassium level of 2.0mEq/L is dangerously low and consistent with the ECG findings in this scenario. Choices A, C, and D have potassium levels that are not reflective of severe hypokalemia, therefore they are incorrect. Option A (4.0mEq/L) is within the normal range, option C (8.0mEq/L) is elevated, and option D (2.6mEq/L) is higher than the correct value of 2.0mEq/L.
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: The correct answer is D, Arcus senilis. This condition does not cause visual problems in the older adult. Arcus senilis is a grayish-white ring around the cornea, which does not affect vision. Glaucoma, macular degeneration, and cataracts are conditions that can lead to visual impairment in older adults. Glaucoma is characterized by increased pressure in the eye, which can damage the optic nerve and lead to vision loss. Macular degeneration affects the central part of the retina, leading to blurred or distorted vision. Cataracts cause clouding of the lens, resulting in decreased vision. Therefore, Arcus senilis is the correct choice as it does not cause visual problems compared to the other conditions listed.