Nokea
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
- A. Terminate the plan of care
- B. Modify the plan of care
- C. Reassign care to another nurse
- D. Reassess the client’s condition
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome.
Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success.
Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step.
Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.
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If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?
- A. Left atrial atrophy
- B. Left ventricular hypertrophy
- C. Right atrial atrophy
- D. Right ventricular hypertrophy
Correct Answer: D
Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: A
Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician.
Rationale:
1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal.
2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache.
3. Following physician's direction is crucial to individualize care based on the specific situation.
Summary of other choices:
B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache.
C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms.
D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Impaired urinary elimination
- D. Risk for body image disturbance
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.
An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
- A. Potential for infection
- B. Self care deficit
- C. Alteration in infection
- D. Fluid volume excess
Correct Answer: A
Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.
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: Rationale: Intrinsic factor is a glycoprotein produced by the stomach that is essential for the absorption of vitamin B12 in the ileum. Without intrinsic factor, vitamin B12 absorption is impaired, leading to megaloblastic anemia. Histamine and hydrochloric acid are not directly involved in vitamin B12 absorption. Liver enzymes are not implicated in the absorption process. Therefore, the correct answer is A.