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A nurse is collecting data from a home care client. In addition to information about the client’s health status, what is another observation the nurse should make?
- A. Number of rooms in the house
- B. Safety of the immediate environment
- C. Frequency of home visits to be made
- D. Friendliness of the client and family
Correct Answer: B
Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.
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The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. “It will raise you BP, which is necessary because of blood loss.”
- B. “It will dilate your bronchioles and make your breathing easier.”
- C. “It will help your blood to clot to reduce bleeding.”
- D. “It will constrict your vessels and slow down the bleeding.”
Correct Answer: D
Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.
A total thyroidectomy is ordered following discovery of a cold nodule. In this case of hyperthyroidism versus malignancy, the nurse anticipates that the patient will have:
- A. A complete thyroidectomy also
- B. a partial thyroidectomy (approximately one-half of the thyroid is removed)
- C. a partial thyroidectomy (approximately five-sixths of the thyroid is removed)
- D. administration of thyroid medication
Correct Answer: A
Rationale: The correct answer is A: A complete thyroidectomy also. In the case of a cold nodule, which indicates potential malignancy, a total thyroidectomy is warranted to remove the entire thyroid gland to prevent the spread of cancer. A partial thyroidectomy, as in choices B and C, would not be sufficient in addressing malignancy. Administering thyroid medication, as in choice D, would not be appropriate for treating malignancy. Therefore, the correct approach is to perform a total thyroidectomy to ensure complete removal of the affected gland and to address both hyperthyroidism and potential malignancy.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: The correct answer is B: Fine needle aspiration. This is because fine needle aspiration involves extracting cells from the lump in the breast for examination under a microscope to determine if they are cancerous. This procedure provides a definitive diagnosis of breast cancer. Breast self-examination (A) is a screening tool for detecting lumps but does not confirm a diagnosis. Mammography (C) is used for screening and detecting abnormalities but requires further testing for confirmation. Chest x-ray (D) is not useful for diagnosing breast cancer.
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
- A. Presence of opportunistic infections
- B. Extent of immune system damage
- C. Level of the viral load
- D. Resistance to antigens
Correct Answer: B
Rationale: Step-by-step rationale:
1. CD4+ cells are a type of white blood cell crucial for immune function.
2. HIV targets and destroys CD4+ cells, leading to immune system damage.
3. Measuring CD4+ levels helps determine the extent of this damage.
4. Therefore, the correct answer is B.
Summary:
A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose.
C: Level of the viral load - Measured separately from CD4+ levels.
D: Resistance to antigens - CD4+ levels do not directly indicate resistance.
A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?
- A. Health status NursingStoreRN
- B. Health behavior
- C. Psychological self-control
- D. Health service utilization
Correct Answer: B
Rationale: The correct answer is B: Health behavior. Evaluating the patient's demonstration of self-injection assesses their ability to perform a specific health-related action. This choice focuses on the patient's actions and behaviors related to their health, aligning with the scenario provided.
Choice A: Health status is incorrect because it refers to the patient's current physical condition, not their ability to perform a specific health action.
Choice C: Psychological self-control is incorrect as it pertains to the patient's ability to regulate their emotions and impulses, not their ability to self-administer injections.
Choice D: Health service utilization is incorrect as it relates to the frequency and pattern of healthcare services used by the patient, not their ability to perform a specific health behavior.