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A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs.
A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations.
C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences.
D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.
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A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: A
Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician.
Rationale:
1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal.
2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache.
3. Following physician's direction is crucial to individualize care based on the specific situation.
Summary of other choices:
B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache.
C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms.
D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.
Which laboratory study is monitored for the patient receiving heparin therapy?
- A. INR
- B. PTT
- C. PT
- D. Bleeding time
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect.
A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin.
C: PT (Prothrombin Time) is also used to monitor warfarin therapy.
D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?
- A. Act as a leader of the health care team.
- B. Develop good communication skills.
- C. Work solely with nurses.
- D. Avoid conflict.
Correct Answer: B
Rationale: The correct answer is B: Develop good communication skills. In interdisciplinary collaboration, effective communication is essential for teamwork. By developing good communication skills, the nurse can effectively interact with other healthcare professionals to provide holistic care. Choice A is incorrect as the nurse should collaborate as part of a team, not necessarily be the leader. Choice C is incorrect as interdisciplinary collaboration involves working with professionals from various disciplines. Choice D is incorrect as conflict resolution is an important aspect of effective collaboration.
A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
- A. “I’ll play card games with my friends.”
- B. “I’ll take a long trip to visit my aunt.”
- C. “I’ll bowl with my team after discharge.”
- D. “I’ll eat lunch in a restaurant everyday.”
Correct Answer: C
Rationale: The correct answer is C because bowling with the team after discharge promotes social interaction and physical activity, addressing both the diversional activity deficit and the decreased energy. Playing card games (A) may not involve physical activity. Taking a long trip (B) may be overwhelming and tiring. Eating in a restaurant daily (D) does not address the need for meaningful activities or social interaction.
A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?
- A. Anemia and fatigue
- B. A noticeable lump in the neck
- C. Crackles and stridor
- D. Dysphagia or hoarseness
Correct Answer: D
Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.