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A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
- A. The client’s diet
- B. The client’s family member’s history of
- C. The client’s drug history chronic diseases
- D. The client’s ability to produce antibodies
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly.
A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function.
B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system.
C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.
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What is the best way to detect testicular cancer early?
- A. Monthly testicular self-examination
- B. Annual physician examination
- C. Yearly digital rectal examination
- D. Annual ultrasonography
Correct Answer: A
Rationale: The correct answer is A: Monthly testicular self-examination. This is the best way to detect testicular cancer early because it allows individuals to become familiar with the normal size, shape, and texture of their testicles, making it easier to notice any changes or abnormalities. Self-examination is cost-effective, convenient, and can be done regularly to monitor for any signs of cancer. Annual physician examination (B) may not be frequent enough for early detection. Yearly digital rectal examination (C) is not relevant for detecting testicular cancer. Annual ultrasonography (D) is not recommended as a routine screening tool for testicular cancer.
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment.
Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow.
Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis.
Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery.
A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion.
B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion.
D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.
Marichu is admitted to the hospital because of hepatic failure and was prescribed with lactulose (Duphalac). The primary action of this drug is:
- A. prevent constipation
- B. decrease resident intestinal flora
- C. increase intestinal peristalsis
- D. prevent portal hypertension
Correct Answer: B
Rationale: The correct answer is B: decrease resident intestinal flora. Lactulose is a synthetic sugar that is not absorbed in the intestine and is used to decrease ammonia levels in patients with hepatic encephalopathy by promoting the growth of beneficial gut bacteria that help metabolize ammonia. This action helps reduce the toxic effects of ammonia on the brain.
A: prevent constipation - Lactulose may help with constipation, but its primary action in this scenario is to decrease resident intestinal flora.
C: increase intestinal peristalsis - Lactulose does not directly increase peristalsis.
D: prevent portal hypertension - Lactulose does not have a direct effect on preventing portal hypertension.
A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.)
- A. Observations of wound healing
- B. Daily blood pressure measurements
- C. Findings of respiratory rate and depth
- D. Completion of nursing interventions NursingStoreRN
Correct Answer: A
Rationale: The correct answer is A: Observations of wound healing. This is the correct evaluative measure because it directly assesses the patient's response to nursing care, indicating the effectiveness of interventions. Wound healing is a tangible and visible indicator of the patient's overall health status and the success of nursing interventions.
The other choices are incorrect:
B: Daily blood pressure measurements do not solely indicate a patient's response to nursing care. Blood pressure can be affected by various factors unrelated to nursing interventions.
C: Findings of respiratory rate and depth are important for assessing respiratory status but may not directly reflect the patient's response to nursing care.
D: Completion of nursing interventions is a process measure and does not provide direct insight into the patient's response to care.