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A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?
- A. The patient rates the pain at 3 to 4 on a 0 to 10 scale
- B. The patient has full ROM of the upper extremities
- C. The patient demonstrates correct self-administration of analgesics
- D. The patient is able to ambulate 25 feet without pain
Correct Answer: D
Rationale: The correct answer is D: The patient is able to ambulate 25 feet without pain. This outcome indicates successful plan implementation for impaired mobility due to nerve compression. Ambulating without pain shows improved mobility and nerve compression relief. Choices A, B, and C do not directly address mobility improvement. Choice A focuses on pain level, which is important but not a direct measure of mobility. Choice B refers to upper extremities, not the lower extremities affected by lumbar disk herniation. Choice C addresses medication management, not mobility improvement.
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For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
- A. Increased weight, hypertension, and insomnia
- B. Vaginal bleeding, jaundice, and inflammation
- C. Stupor, breast lumps, and pain
- D. Dyspnea, numbness, and headache
Correct Answer: A
Rationale: The correct answer is A. Prednisone is a corticosteroid that can cause adverse reactions such as increased weight due to fluid retention, hypertension due to sodium retention, and insomnia due to its stimulating effects. Vaginal bleeding, jaundice, inflammation, stupor, breast lumps, pain, dyspnea, numbness, and headache are not commonly associated with prednisone use. Monitoring for weight changes, blood pressure, and sleep patterns is essential when administering prednisone to a client with rheumatoid arthritis for early detection and management of adverse reactions.
The examiner shines a light in the patient’s eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner’s finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?
- A. Pupils 2 mm
- B. PERRLA
- C. Pupils constricted
- D. Pupils normal
Correct Answer: B
Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation.
Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment. Choice C is too vague, as it does not specify the exact response of the pupils. Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation. Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
- A. The nurse provides assistance while the patient is walking in the hallways.
- B. The patient is able to ambulate in the hallway with crutches.
- C. The patient will deny pain while walking in the hallway.
- D. The patient’s level of mobility will improve.
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery.
A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived?
- A. The defining characteristics
- B. The related factors
- C. The problem statement
- D. The database
Correct Answer: C
Rationale: During outcome identification and planning, outcomes are derived from the problem statement of the nursing diagnoses. This is because the problem statement clearly defines the patient's health issue or condition that needs to be addressed, thus guiding the development of specific, measurable, and achievable outcomes. The defining characteristics (choice A) describe the signs and symptoms of the health problem but do not directly lead to outcome identification. The related factors (choice B) represent the potential causes or contributing factors to the health problem and are not used to derive outcomes. The database (choice D) consists of the patient's health history, assessment data, and laboratory findings, which are essential for diagnosing but do not directly determine outcomes. Therefore, the correct answer is C as it directly informs the outcomes to be achieved.
What is an important consideration regarding TPN administration?
- A. IV site is kept aseptic while infusing the solution
- B. Feeding is poured into a pouch and then infused
- C. Solution is only hung for a maximum of 8 hours at a time
- D. New formula is added as needed so the line does not run dry
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Aseptic technique prevents infection at IV site.
2. TPN is a high-risk solution, requiring strict aseptic administration.
3. Contaminated site can lead to sepsis or other serious complications.
4. Choice B increases risk of contamination.
5. Choice C increases risk of bacterial growth.
6. Choice D may introduce air or contamination.
Summary:
Choice A is correct as it emphasizes infection prevention. Choices B, C, and D pose risks of contamination, bacterial growth, or air introduction.