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A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
- A. “My leg hurts so bad. I can’t stand it.”
- B. “Appears anxious and frightened.”
- C. “I am so sick; I am about to throw up.”
- D. “Unable to palpate femoral pulse in left leg.”
Correct Answer: D
Rationale: The correct answer is D because "Unable to palpate femoral pulse in left leg" is an objective finding that can be measured or observed without interpretation or bias. It provides concrete, measurable information about the patient's condition. Choices A, B, and C are subjective data as they rely on the patient's feelings, emotions, and perceptions, which can vary and are open to interpretation. Objective data is crucial in making accurate assessments and decisions in healthcare.
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Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care.
Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Rationale:
1. Following thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypocalcemia.
2. Symptoms of hypocalcemia include muscle twitching, hyperirritability, numbness, and tingling.
3. These symptoms align with the client's presentation, indicating a probable electrolyte imbalance.
4. Hypocalcemia is a common complication post-thyroidectomy due to parathyroid gland damage.
5. Prompt recognition and treatment of hypocalcemia are essential to prevent severe complications.
Summary:
B: Hyperkalemia - Not typically associated with thyroid surgery, symptoms differ.
C: Hyponatremia - Unlikely post-thyroidectomy, symptoms don't match presentation.
D: Hypermagnesemia - Rare post-thyroidectomy, symptoms and electrolyte disturbance don't align.
What is the focus of a diagnostic statement for a collaborative problem?
- A. The client problem
- B. The potential complication
- C. The nursing diagnosis
- D. The medical diagnosis
Correct Answer: B
Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying any potential complications that may arise due to the client's condition or treatment. This allows nurses and other healthcare professionals to anticipate and address these complications proactively.
A: The client problem - While important, the client problem is usually addressed in the nursing diagnosis rather than the diagnostic statement for a collaborative problem.
C: The nursing diagnosis - The nursing diagnosis focuses on the actual or potential health problems that the client is experiencing, which is different from the focus of a diagnostic statement for a collaborative problem.
D: The medical diagnosis - The medical diagnosis is the identification of a disease or condition by a healthcare provider, which is not the focus when identifying potential complications in a collaborative problem.
An adult is to receive an IM injection of Morphine for post op pain. Which of the following is necessary for the nurse to assess prior to giving a narcotic analgesic?
- A. The client’s level of alertness and respiratory rate
- B. The last time the client ate or drank something
- C. The client’s bowel habits and last bowel movement
- D. The client’s history of addictions
Correct Answer: A
Rationale: The correct answer is A. Before administering a narcotic analgesic like Morphine, assessing the client's level of alertness and respiratory rate is crucial to ensure they can tolerate the medication without compromising their breathing. Alertness indicates their ability to handle potential side effects, while respiratory rate is vital to monitor for any signs of respiratory depression.
Choice B (last meal) is not directly related to giving a narcotic analgesic, although it may impact the absorption rate. Choice C (bowel habits) and last bowel movement are not immediately relevant to assessing the client's readiness for a narcotic analgesic. Choice D (history of addictions) is important but not the priority when assessing for immediate safety and efficacy of the medication.
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein
- B. The head and back are immobilized mechanically with a cervical collar and back support
- C. Traction with weights and pulleys is applied
- D. A turning frame is used EMERGENCY AND DISASTER NURSING SITUATION: A group of high school teenagers went camping to Sohoton this summer for one week. You are the nurse assigned to this camp. For the first three days, you were busy with several emergencies.
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.