A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery-this will go away on its own”. In considering her response to the client, the nurse must depend on the ethical principle of:
- A. Beneficence
- B. Advocacy
- C. Autonomy
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.
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After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
- A. To form a language that can be encoded only by nurses
- B. To distinguish the nurse’s role from the physician’s role
- C. To develop clinical judgment based on other’s intuition
- D. To help nurses focus on the scope of medical practice
Correct Answer: D
Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on their scope of practice, which involves identifying and addressing the patient's nursing care needs. By formulating a specific nursing diagnosis, nurses can prioritize interventions and provide individualized care. Choice A is incorrect as nursing diagnoses are not exclusive to nurses. Choice B is incorrect because nursing and physician roles overlap. Choice C is incorrect as clinical judgment should be based on evidence and critical thinking, not solely on intuition.
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
- A. fluid volume excess
- B. incontinence, bowel
- C. fluid volume deficit
- D. diarrhea
Correct Answer: C
Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
- A. status of client’s tetanus immunization
- B. current blood alcohol level
- C. support systems available at home to assist with care
- D. last time client voided
Correct Answer: A
Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications.
Incorrect choices:
B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture.
C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority.
D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.
Biopsy is a diagnostic procedure which:
- A. Detects the presence of malignant cells
- B. Measures hemoglobin content
- C. Measures the RBC size
- D. Detects arterial occlusion Situation: Cancer ranks third in leading cause of morbidity and mortality in the Philippines. Early detection Increases the survival rate of those afflicted. You are a nurse in a cancer-prevention and screening clinic and are for health education.
Correct Answer: A
Rationale: The correct answer is A: Detects the presence of malignant cells. Biopsy involves taking a sample of tissue to examine under a microscope for the presence of abnormal or cancerous cells. This procedure is crucial for diagnosing cancer accurately.
Choice B (Measures hemoglobin content) is incorrect because hemoglobin content is typically measured through blood tests, not biopsies.
Choice C (Measures the RBC size) is incorrect as RBC size is usually assessed through a complete blood count (CBC) test, not a biopsy.
Choice D (Detects arterial occlusion) is incorrect because arterial occlusion is typically diagnosed through imaging studies like Doppler ultrasound or angiography, not through a biopsy procedure.
Rehabilitation plans for Mr. Gabatan;
- A. Should be left up to Mr. Gabatan and his family
- B. Should be considered and planned for early in his care
- C. Are not necessary, because he will return to former activities
- D. Are not necessary, because he will probably not able to work again Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an executive to the hospital director. She is alert, oriented and eager to return to her job as an executive assistant to the hospital director. She calls the nurse to her room to express her concern about the frequency of urination she is experiencing, as well as the feeling of weakness that began this morning.
Correct Answer: B
Rationale: Rationale for Correct Answer B: Rehabilitation plans for Mr. Gabatan should be considered and planned for early in his care to optimize his recovery and quality of life. Planning early allows for tailored interventions to address his specific needs and goals, promoting better outcomes. Early rehabilitation can also prevent complications and improve functional abilities. By proactively addressing rehabilitation needs, Mr. Gabatan can have a smoother transition back to his daily activities.
Summary of Incorrect Choices:
A: Leaving the rehabilitation plans solely up to Mr. Gabatan and his family may not consider all aspects of his recovery and could lead to suboptimal outcomes.
C: Assuming that Mr. Gabatan will return to his former activities without a rehabilitation plan overlooks the individualized care needed for his recovery.
D: Dismissing the need for rehabilitation based on the assumption that he may not be able to work again is premature and does not account for potential improvements in his condition through appropriate rehabilitation interventions.