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A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
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Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: The correct answer is A. When someone is extremely confused, providing new information slowly and in small amounts can help prevent overwhelming stress and further confusion. This approach allows the individual to process information more effectively and reduces the risk of escalating confusion or delirium as a defense mechanism. Choices B, C, and D are incorrect because destruction of brain cells, teaching progression, and giving minimal information are not directly related to managing confusion in this scenario.
The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
- A. hypotension
- B. thick, coarse skin
- C. deposits of adipose tissue in the trunk and dorsocervical area
- D. weight gain in arms and legs
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat.
A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation.
B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation.
D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.
Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: The correct answer is B, anaphylactic shock and angioedema, as it is the most severe complication of allergies and can be life-threatening. Anaphylactic shock can lead to airway constriction, severe drop in blood pressure, and organ failure. Angioedema can cause swelling of the face, lips, and throat, leading to difficulty breathing. Bronchitis (A) is a respiratory condition that can occur due to allergies but is not typically life-threatening. Cardiac arrest (C) is a serious complication but not directly related to allergies. Asthma and nasal polyps (D) are common allergic conditions but are not as immediately life-threatening as anaphylactic shock.
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
- A. Placement of IV and central venous pressure lines
- B. Administrating cleansing enemas
- C. Observing for leakage of urine or stool from the anastomosis
- D. Assessing the clients ability to manage self catheterization
Correct Answer: C
Rationale: The correct answer is C: Observing for leakage of urine or stool from the anastomosis. This is crucial in nursing management post-urinary diversion procedure to prevent complications such as infection, dehydration, and skin breakdown. Leakage can indicate issues with the surgical site integrity and requires prompt intervention.
A: Placement of IV and central venous pressure lines is important but not as critical as monitoring for leakage from the anastomosis.
B: Administering cleansing enemas may be necessary for certain procedures but is not the most important factor in this case.
D: Assessing the client's ability to manage self-catheterization is important for long-term care but does not take precedence over monitoring for potential complications like leakage.
In summary, option C is the most important factor as it directly impacts the client's immediate post-operative care and helps prevent serious complications.
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
- A. Sleep with the head of the bed slightly
- B. Use a soft toothbrush and electric razor
- C. Drink citrus juices frequently for nourishment
- D. Increase his activity level and ambulates frequently
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because:
A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression.
C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding.
D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.