Nokea
A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
- A. States feels better after talking with family and friends
- B. Consumes high-carbohydrate foods when stressed
- C. Dislikes the support group meetings
- D. Spends most of the day in bed
Correct Answer: A
Rationale: The correct answer is A because stating feeling better after talking with family and friends demonstrates the use of healthy coping skills. This behavior indicates the patient is seeking and utilizing social support, which is crucial for managing stress and emotions effectively in diabetes management. Choices B, C, and D are incorrect because consuming high-carbohydrate foods when stressed can lead to poor blood sugar control, disliking support group meetings indicates avoidance of beneficial support resources, and spending most of the day in bed can contribute to physical and emotional deterioration, rather than effective coping.
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The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the ff. interventions is most important for the nurse to do before the procedure?
- A. Explain the procedure to the patient’s family
- B. Observe the patient for bleeding
- C. Administer an analgesic to the patient
- D. Drape the biopsy site
Correct Answer: B
Rationale: The correct answer is B: Observe the patient for bleeding. Before a bone marrow biopsy, it is crucial to monitor the patient for bleeding tendencies as the procedure can cause bleeding. This step ensures early detection and prompt intervention if bleeding occurs.
Explanation for other choices:
A: Explaining the procedure to the family is important for informed consent but not the most crucial before the procedure.
C: Administering an analgesic may be necessary for pain management but monitoring for bleeding takes precedence.
D: Draping the biopsy site is important for maintaining a sterile field but does not directly impact patient safety like monitoring for bleeding.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. First, the nurse needs to assess the severity of the latex allergy to determine the appropriate interventions. Understanding the type of reaction can help guide treatment and prevent future exposure. Isolating the patient (choice A) is not necessary unless there is a severe reaction. Terminating the interview (choice C) prematurely is not appropriate as crucial information may be missed. Documenting the allergy (choice D) is important but not as urgent as assessing the reaction type.
Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:
- A. Urinary output
- B. Serum ammonia level
- C. Abdominal girth
- D. Hepatic encephalopathy
Correct Answer: C
Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing.
B: Applying talcum powder can actually worsen skin irritation and should be avoided.
C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity.
D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.
Five girls were victims of wasp and bee bites. Emergency treatment for these includes:
- A. A poultice of sodium bicarbonate and water may give relief
- B. A weak solution of household ammonia also decreases pain and is safe to use
- C. A and B are correct
- D. None of these
Correct Answer: A
Rationale: The correct answer is A because a poultice of sodium bicarbonate and water can help neutralize the venom and reduce pain from wasp and bee bites. Sodium bicarbonate has alkaline properties that can counteract the acidic venom. Option B is incorrect as household ammonia can cause skin irritation and should not be applied to insect bites. Option C is incorrect because only option A is a safe and effective treatment for wasp and bee bites. Option D is incorrect as there is a suitable emergency treatment available.