Nokea
A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
- A. Administer IV fluids and blood transfusions
- B. Administer narcotic analgesics as prescribed
- C. Encourage fluid intake of 3000ml/day
- D. Suggest taking herbs or spices to increase food palatability
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day
Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation.
Incorrect Choices:
A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection.
B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection.
D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.
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A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale:
1. Asking about chief concerns helps to focus the interview on the patient's needs.
2. It demonstrates active listening and empathy.
3. Allows the nurse to prioritize issues and provide appropriate care.
4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.
In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?
- A. Etiology
- B. Problem
- C. Defining characteristics
- D. Client need
Correct Answer: A
Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: Rationale:
1. Digital rectal exam (DRE) and PSA test are recommended by major health organizations for prostate cancer screening in men over 50.
2. DRE helps detect abnormalities in the prostate, while PSA test measures the levels of a protein produced by the prostate gland.
3. Prostate cancer can be asymptomatic in its early stages, so regular screening is crucial for early detection and treatment.
4. Transrectal ultrasound is not a primary screening method for prostate cancer.
5. Testicular self-exams are for detecting testicular cancer, not prostate cancer.
6. CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.
Three days after admission Ms. CC continued to have frequent stools. Her oral intake of both fluids and solids are poor. Her physician ordered parenteral hyperalimentation. Hyperalimentation solutions are:
- A. Hypotonic solutions used primarily to increase osmotic pressure of blood plasma
- B. Hypertonic solutions used primarily for hydration when hemoconcentration is present
- C. Alkalizing solutions used to treat metabolic acidosis thus reducing cellular sweating
- D. Hyperosmolar solutions used primarily to reverse negative nitrogen balance
Correct Answer: D
Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance.
Rationale:
1. Hyperalimentation solutions are designed to provide essential nutrients intravenously.
2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition.
3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake.
4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance.
Summary:
A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it.
B: Hypertonic solutions are not primarily used for hydration in this context.
C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.
Which of the following would indicate that the patient has a normal corneal light reflex?
- A. The eye focuses the image in the center of the pupil.
- B. The eyes converge to focus on the light.
- C. Constriction of both pupils occurs in response to bright light.
- D. Light is reflected at the same spot in both eyes.
Correct Answer: D
Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.