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A nurse admits an older patient to the emergency room with reports of shortness of breath on exertion and a productive cough. The nurse reviews the patient's current medications and the patient says, “I take one pink pill every morning.†The nurse asks the name of the drug and the patient says she doesn't know. This happens with four other medications the patient says she takes. What is an appropriate nursing diagnosis for this patient?
- A. Ineffective health maintenance.
- B. Noncompliance.
- C. Acute confusion.
- D. Risk-prone health behavior.
Correct Answer: A
Rationale: The correct answer is A: Ineffective health maintenance. This diagnosis is appropriate because the patient's inability to identify their medications indicates a lack of understanding and engagement in managing their own health. The patient's confusion about their medications can lead to noncompliance and potential health risks. The other choices are not as appropriate because the patient's issue is related to a lack of knowledge and understanding rather than deliberate noncompliance (B), acute confusion (C), or a risky behavior (D). To address the issue, the nurse should focus on education and support to improve the patient's health maintenance skills.
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The patient newly diagnosed with epilepsy asks the nurse to explain the meaning of the diagnosis. What is the nurse's best response?
- A. Epilepsy is the clonic-tonic muscle contraction with the potential to cause injury.
- B. Epilepsy is a convulsive disorder caused by electrical discharge in the muscle.
- C. Epilepsy is a single disease.
- D. Epilepsy is characterized by sudden discharge of electrical energy.
Correct Answer: D
Rationale: The correct answer is D because epilepsy is defined by sudden discharges of electrical energy in the brain leading to seizures. This explanation is accurate and specific to the condition. Choice A is incorrect because epilepsy encompasses various types of seizures, not just clonic-tonic muscle contractions. Choice B is incorrect as it simplifies epilepsy to being solely convulsive, disregarding non-convulsive seizures. Choice C is incorrect because epilepsy is a spectrum of disorders.
The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in the patient?
- A. Gastrointestinal (GI) and lower extremity muscles.
- B. Central nervous system (CNS), memory, and cognition.
- C. Respiratory and facial muscles.
- D. Cardiovascular system and postural muscles.
Correct Answer: C
Rationale: The correct answer is C: Respiratory and facial muscles. Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. Symptoms commonly affect muscles involved in breathing (respiratory) and facial expressions, such as difficulty swallowing, breathing, speaking, and facial drooping. Monitoring these systems is crucial as respiratory muscle weakness can lead to respiratory failure. Choice A is incorrect because myasthenia gravis does not typically affect gastrointestinal or lower extremity muscles primarily. Choice B is incorrect as the primary symptoms of myasthenia gravis do not involve the central nervous system but rather the neuromuscular junction. Choice D is incorrect as myasthenia gravis does not directly impact the cardiovascular system or postural muscles.
A patient has been taking Sertraline (Zoloft) 20mg/ml oral concentrate 1ml daily for several weeks and reports being unable to sleep well. What will the nurse do next?
- A. Ask the patient what time of day the medication is taken.
- B. Recommend asking the provider about weekly dosage.
- C. Counsel the patient to take the medication at bedtime.
- D. Suggest that the patient request a lower dose.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient what time of day the medication is taken. This is because insomnia can be a common side effect of sertraline, and taking it at a different time of day may help alleviate this issue. By understanding the timing of the medication intake, the nurse can assess if adjusting the administration time may improve the patient's sleep. Option B is not directly related to addressing the sleep concern. Option C may help but does not address the timing issue. Option D is premature without assessing the current timing.
What action does the nurse take during the intervention stage of the nursing process related to drug therapy? (Select all that apply)
- A. Analyze the data collected.
- B. Collect a nursing history.
- C. Determine medication effectiveness.
- D. Document the medication.
- E. Administer the medication.
Correct Answer: C,D,E
Rationale: During the intervention stage of the nursing process related to drug therapy, the nurse's actions include determining medication effectiveness (C) to ensure the treatment is achieving its intended outcomes. Documenting the medication (D) is crucial for maintaining accurate records of administration and monitoring. Administering the medication (E) is essential for providing the prescribed treatment to the patient. Analyzing data (A) is typically done during the assessment phase, not the intervention phase. Collecting a nursing history (B) is part of the assessment phase. Other choices are not directly related to the intervention stage of drug therapy.
When involved in phase III drug evaluation studies, what responsibilities would the nurse have?
- A. Working with animals who are given experimental drugs.
- B. Conducting research to determine the effectiveness of the drug.
- C. Monitoring and observing patients closely for adverse effects.
- D. Choosing appropriate patients to be involved in the study.
Correct Answer: C
Rationale: The correct answer is C because in phase III drug evaluation studies, nurses are responsible for monitoring and observing patients closely for any adverse effects of the experimental drug. This is crucial to ensure patient safety and to gather data on the drug's efficacy and safety profile. Nurses play a key role in identifying and reporting any adverse reactions promptly.
Choice A is incorrect as nurses do not work with animals in drug evaluation studies.
Choice B is incorrect as conducting research to determine drug effectiveness is typically done by researchers and physicians, not nurses.
Choice D is incorrect as choosing appropriate patients for the study is usually the responsibility of the study's principal investigator or a designated research team.