Nokea
A nurse has been caring for a client with chronic obstructive pulmonary disease (COPD). What should the nurse focus on during the evaluation phase?
- A. Documenting all interventions performed
- B. Reviewing the client’s progress toward meeting goals
- C. Delegating further care to another healthcare professional
- D. Ensuring compliance with all physician orders
Correct Answer: B
Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan.
A: Documenting interventions is important but not the primary focus during the evaluation phase.
C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan.
D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.
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A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate?
- A. If the client and her sexual partners are HIV positive, unprotected sex is permitted
- B. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse
- C. Contraceptive methods like birth control pills, implants, and injections are recommended to prevent HIV transmission
- D. The intrauterine device is recommended for a client with HIV
Correct Answer: B
Rationale: The correct answer is B: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
Rationale:
1. Latex condoms create a physical barrier that helps prevent the exchange of bodily fluids containing HIV.
2. Spermicide can further reduce the risk of HIV transmission by killing some viruses and bacteria.
3. Research shows that consistent and correct use of condoms is highly effective in reducing the risk of HIV transmission.
4. Other choices are incorrect:
- A: Unprotected sex between HIV-positive individuals can lead to the transmission of drug-resistant strains or different strains of HIV.
- C: Contraceptive methods like birth control pills do not protect against HIV transmission.
- D: The intrauterine device is not specifically recommended for clients with HIV due to potential risks of infection.
The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Hypernatremia
- C. Reduced blood urea nitrogen (BUN)
- D. Hyperglycemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to electrolyte imbalances. This results in increased potassium levels (hyperkalemia) due to lack of aldosterone to promote potassium excretion. Hypernatremia (choice B) is less likely as aldosterone deficiency leads to sodium loss. Reduced BUN (choice C) is unlikely as Addison's crisis does not directly affect urea levels. Hyperglycemia (choice D) is not typically seen in Addisonian crisis as cortisol deficiency usually results in hypoglycemia.
Which of the following examples of client data needs to be validated?
- A. A client has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a client with a respiratory infection documents fever and chills.
- D. A client in a nursing home states that she is unable to eat the food being served.
Correct Answer: A
Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight.
- Choice B is about interpreting physical signs, not client data validation.
- Choice C involves documenting objective findings, not validating client information.
- Choice D pertains to a client's complaint, not necessarily requiring validation.
Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson’s or Huntington’s diseases, or even epilepsy?
- A. Because clients suffer from depression, anxiety, and inability to perform basic self care
- B. Because clients become paralytic throughout the body
- C. Because the clients bone become weak, brittle, and painful to even move
- D. Because clients generally become very aggressive and violent with other people CARING FOR CLIENTS WITH NEUROLOGIC DEFICITS
Correct Answer: A
Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks.
Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client’s temperature before, during, and after transfusion
- B. Documenting the client’s temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client’s temp with the temp of the blood
Correct Answer: A
Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction.
Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.