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A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will cause the nurse manager to intervene?
- A. Wandering
- B. Hemorrhage NursingStoreRN
- C. Urinary retention
- D. Impaired swallowing
Correct Answer: B
Rationale: The correct answer is B: Hemorrhage. The nurse manager would intervene because hemorrhage is a life-threatening condition requiring immediate attention. Wandering (A), urinary retention (C), and impaired swallowing (D) are important assessments but do not pose the same level of immediate risk as hemorrhage. The nurse manager would prioritize addressing the hemorrhage to ensure the patient's safety and well-being.
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Mrs. Tan is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which of the following is the priority goal for her immediately after the procedure?
- A. prevent fluid volume deficit
- B. maintain blood pressure control
- C. decrease myocardial contractility
- D. minimize dyspnea
Correct Answer: B
Rationale: The correct answer is B: maintain blood pressure control. After PTCA, the priority goal is to ensure stable hemodynamics. Maintaining blood pressure control is crucial to prevent complications such as bleeding or thrombosis. Choices A, C, and D are incorrect because preventing fluid volume deficit, decreasing myocardial contractility, and minimizing dyspnea are not immediate priorities post-PTCA. Oxygenation and hemodynamic stability take precedence over these concerns.
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
- A. Is written as a two-part statement
- B. Describes human response to a health problem
- C. Describes potential for enhancement to a higher state
- D. Made when not enough evidence supports the problem
Correct Answer: A
Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue.
Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
- A. slap the chest wall gently
- B. use vibration techniques to move secretions from affected lung areas during the inspiration phase
- C. perform CPT at least two hours after meals
- D. plan apical drainage at the beginning of the CPT session
Correct Answer: C
Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.
A nurse has been examining the vital signs of the client for the past 2 days. On a particular day, she observe a sudden change in the vital signs of the client. Which of the ff steps should the nurse take immediately?
- A. Inform the physician
- B. Change the environmental settings of the client
- C. Alter the diet intake of the client
- D. Decrease the physical activity of the client if any.
Correct Answer: A
Rationale: The correct answer is A: Inform the physician. This is essential because a sudden change in vital signs may indicate a critical condition that requires immediate medical attention. The physician needs to be informed promptly to assess the situation and provide appropriate interventions.
Summary:
- B: Changing environmental settings is not a priority when dealing with sudden changes in vital signs.
- C: Altering diet intake is not an immediate response to sudden changes in vital signs.
- D: Decreasing physical activity may not address the underlying cause of the sudden change in vital signs.
Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
- A. Increased ICP
- B. Parasympathetic response
- C. Sympathetic response
- D. Increased cerebral blood flow
Correct Answer: A
Rationale: The correct answer is A: Increased ICP. Decreasing level of consciousness is a classic sign of increased intracranial pressure (ICP) due to the compression of the brain. As ICP rises, it impairs cerebral perfusion leading to altered mental status. Parasympathetic response (B) and sympathetic response (C) are related to autonomic nervous system functions, not consciousness. Increased cerebral blood flow (D) might lead to conditions like hyperemia but does not directly cause a decreased level of consciousness.