Nokea
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 their health care. By focusing on the patient's expectations, the nurse can establish a therapeutic relationship, provide patient-centered care, and tailor the care plan accordingly.
A: Nurse's concerns - Incorrect. The nursing health history should prioritize the patient's perspective and needs over the nurse's concerns.
C: Current treatment orders - Incorrect. While important, this component focuses on the medical treatment plan rather than the patient's expectations.
D: Nurse's goals for the patient - Incorrect. The nurse should collaborate with the patient to set goals that align with the patient's needs and preferences, not impose their own goals.
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According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Impaired urinary elimination
- D. Risk for body image disturbance
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.
Which of the ff. interventions can help minimize complications related to Hypercalcemia?
- A. Encourage 3 to 4 L of fluid daily
- B. Place the patient on bed rest
- C. Have the patient cough and deep
- D. Apply heat to painful areas breathe every 2 hours
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Hypercalcemia can lead to dehydration due to increased urine output.
2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium.
3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia.
Summary of why other choices are incorrect:
- Choice B (bed rest) does not directly address hypercalcemia complications.
- Choice C (cough and deep breathe) is unrelated to managing hypercalcemia.
- Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
- A. “A man should wear a latex condom during intimate sexual contact.”
- B. “I’ve heard about people who got AIDS from blood transfusions.”
- C. “I won’t donate blood because I don’t want to get AIDS.”
- D. “IV drug users can get HIV from sharing needles.”
Correct Answer: C
Rationale: The correct answer is C. This statement warrants clarification as donating blood does not put individuals at risk of getting HIV. Blood donation involves a sterile process that ensures safety. Choice A is correct as using condoms can help prevent the transmission of HIV. Choice B is incorrect because modern blood screening techniques have greatly reduced the risk of HIV transmission through blood transfusions. Choice D is also correct as sharing needles is a high-risk behavior for HIV transmission. In summary, only choice C is incorrect as donating blood does not pose a risk of acquiring HIV.
A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?
- A. Abdominal pain
- B. Serous drainage from the incision
- C. Hypoactive bowel sounds
- D. Shallow breathing and increasing lethargy
Correct Answer: D
Rationale: The correct answer is D: Shallow breathing and increasing lethargy. This finding could indicate a potential respiratory complication such as atelectasis or pneumonia, which are common postoperative complications. Shallow breathing can lead to inadequate oxygenation and ventilation, causing lethargy due to decreased oxygen delivery to tissues. It is crucial to assess and address respiratory issues promptly to prevent further complications.
A: Abdominal pain is expected postoperatively and can be managed with pain medications.
B: Serous drainage from the incision is a normal finding after surgery and indicates the wound is healing properly.
C: Hypoactive bowel sounds are common after surgery due to decreased peristalsis and can be managed with interventions such as early ambulation and medications.
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process
- B. A reflection of coping mechanisms used to deal with the exacerbation of her illness
- C. Indicative of the remission phase of her chronic illness
- D. Realistic for her current level of physical functioning
Correct Answer: B
Rationale: The correct answer is B because Toni's behavior of minimizing her visual problems, focusing on future goals, seeking information about job opportunities, and expressing desire for more children reflects coping mechanisms used to deal with the exacerbation of her illness. This behavior suggests that she is trying to maintain a sense of normalcy and control in the face of her health challenges.
A: Inappropriate euphoria is excessive happiness or excitement, which is not evident in Toni's behavior.
C: Remission phase typically involves a decrease in symptoms, which is not reflected in Toni's situation.
D: Realistic for her current level of physical functioning does not explain her behavior as coping mechanisms.