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A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
- A. Administer pain medication every 4 hours as needed.
- B. Turn the patient every 2 hours, even hours. NursingStoreRN
- C. Monitor vital signs, especially rhythm.
- D. Keep the bed side rails up at all times.
Correct Answer: B
Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.
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When teaching a preoperative older patient, which of the following is a technique to improve learning?
- A. Sit in front of window in bright sunlight.
- B. Speak in high tone.
- C. Use small, white-on-black printed
- D. Eliminate background noise. materials.
Correct Answer: D
Rationale: The correct answer is D, "Eliminate background noise." This technique is essential for older patients as they may have age-related hearing impairments. By reducing background noise, the patient can better focus on the information being conveyed. Sitting in bright sunlight (A) may cause glare and make it difficult to read or see clearly. Speaking in a high tone (B) may be perceived as aggressive or patronizing. Using small, white-on-black printed materials (C) may be challenging for older patients with visual impairments. Thus, eliminating background noise is the most effective technique to improve learning in preoperative older patients.
A patient is diagnosed with acute bacterial conjunctivitis. In providing patient teaching the nurse would tell the patient that this condition is more commonly known as which of the following?
- A. Glaucoma
- B. Color blindness
- C. Astigmatism
- D. Pinkeye
Correct Answer: D
Rationale: The correct answer is D: Pinkeye. Acute bacterial conjunctivitis is commonly referred to as "pinkeye" due to the characteristic pink or red appearance of the eye. This condition is caused by a bacterial infection of the conjunctiva, the thin membrane that covers the white part of the eye and inner eyelids. The term "glaucoma" (A) refers to a different eye condition characterized by increased intraocular pressure, while "color blindness" (B) is a genetic condition affecting color vision. "Astigmatism" (C) is a refractive error related to the shape of the cornea or lens, not an infection of the eye. Therefore, the correct answer is D as it accurately identifies the common name for acute bacterial conjunctivitis.
The effectiveness of Levodopa can be reduced when taking:
- A. Pyridoxine
- B. Bromocriptine
- C. Amantadine
- D. Amantadine
Correct Answer: A
Rationale: The correct answer is A: Pyridoxine. Pyridoxine can reduce the effectiveness of Levodopa by converting it into dopamine before it reaches the brain, decreasing the therapeutic effects. Bromocriptine and Amantadine are actually used in combination with Levodopa to enhance its effects by different mechanisms. Choosing Amantadine as the answer is incorrect because it is listed twice in the choices and would not interfere with Levodopa's effectiveness.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.” DISTURBANCES IN IMMUNOLOGIC FUNCTIONING
Correct Answer: E
Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?
The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?
- A. Cognitive
- B. Interpersonal
- C. Psychomotor
- D. Judgmental
Correct Answer: B
Rationale: The correct answer is B: Interpersonal. The nurse is using interpersonal skills by establishing trust and communicating with the patient before administering the injection. This helps build rapport and alleviate anxiety. Cognitive skills involve problem-solving and critical thinking, not direct patient interaction. Psychomotor skills relate to physical tasks like giving injections. Judgmental skills involve making decisions based on critical thinking, not directly related to patient communication.