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A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? “Evaluative measures are multiple-page documents used to evaluate nurse
- A. performance.” NursingStoreRN “Evaluative measures include assessment data used to determine whether patients
- B. have met their expected outcomes and goals.” “Evaluative measures are used by quality assurance nurses to determine the progress
- C. a nurse is making from novice to expert nurse.”
- D. “Evaluative measures are objective views for completion of nursing interventions.”
Correct Answer: B
Rationale: The correct answer is B because evaluative measures in nursing refer to the assessment data used to determine if patients have achieved their expected outcomes and goals. This is crucial in evaluating the effectiveness of the care provided.
Choice A is incorrect because it defines evaluative measures as multiple-page documents, which is not accurate. Choice C is incorrect as it focuses on the progression of a nurse's skill level rather than patient outcomes. Choice D is incorrect as it defines evaluative measures as objective views of completing nursing interventions, which is too narrow of a definition.
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A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100mcg IM daily. Which substance influences Vitamin B12 absorption?
- A. Intrinsic factor
- B. Histamine
- C. Hydrochloric acid
- D. Liver enzyme
Correct Answer: A
Rationale: Step 1: Vitamin B12 is absorbed in the small intestine with the help of intrinsic factor produced by parietal cells in the stomach.
Step 2: Intrinsic factor binds to vitamin B12, forming a complex that is then absorbed in the ileum.
Step 3: If intrinsic factor is lacking (as seen in pernicious anemia), vitamin B12 absorption is impaired, leading to megaloblastic anemia.
Step 4: Administering cyanocobalamin bypasses the need for intrinsic factor.
Step 5: Thus, intrinsic factor influences Vitamin B12 absorption. Other choices (B, C, D) do not play a direct role in Vitamin B12 absorption.
A client has been diagnosed with renal failure and is admitted for dialysis. Which of the ff is the nurse’s responsibility as the client undergone dialysis?
- A. Keeping dialysis supplies in a clean area
- B. Inspecting the catheter insertion site for signs of infection
- C. Weighing the client before and after the procedure
- D. washing hands before and after handling the catheter
Correct Answer: C
Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed.
A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure.
B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis.
D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.
60 year-old Mrs. Torres arrived just in time for her doctor’s appointment. She complains of pain and stiffness in her back. She is suspected of having osteoporosis. Nurse Ariane will inform Mrs. Torres that the primary complication of osteoporosis is:
- A. Increased trabeculae
- B. poor posture
- C. chronic pain
- D. fractures
Correct Answer: D
Rationale: The correct answer is D: fractures. Osteoporosis weakens bones, making them more prone to fractures. Fractures are the primary complication of osteoporosis due to decreased bone density. Increased trabeculae (A) is incorrect as osteoporosis leads to decreased bone density, not increased. Poor posture (B) may be a result of osteoporosis but is not its primary complication. Chronic pain (C) can occur with osteoporosis but is not as directly linked as fractures.
Which of the ff is the primary sign of breast cancer?
- A. A bloody discharge from the nipple
- B. A retraction of the nipple
- C. A dimpling of the skin over the lesion
- D. A painless mass in the breast CLIENT IN BIOLOGICAL CRISIS MANAGEMENT of PATIENTS with COMPLICATIONS from HEART DISEASE
Correct Answer: D
Rationale: The correct answer is D: A painless mass in the breast. This is the primary sign of breast cancer because most breast cancers present as painless lumps or masses. This is due to the abnormal growth of cells forming a tumor. Other choices (A, B, C) are also signs of breast cancer, but they are not as common or primary as the presence of a painless mass. A bloody discharge from the nipple (A) can be a sign of a benign condition or cancer, but it is not the most common presentation. Nipple retraction (B) and dimpling of the skin over the lesion (C) can also be signs of breast cancer, but they usually occur in later stages of the disease. Therefore, the presence of a painless mass in the breast is the primary sign that should raise suspicion for breast cancer.
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.