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A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? NursingStoreRN
- A. Patient wanders halls at night.
- B. Patient’s side rails are up with bed alarm activated.
- C. Patient denies pain while ambulating with assistance.
- D. Patient correctly states names of family members in the room.
Correct Answer: D
Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.
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Aling Iska, a 78-year old client consults with a hemoglobin and hematocrit levels of 11mg/dl and 32 % respectively. These finding indicates:
- A. nothing because these are normal findings
- B. the nurse should conduct a thorough nutritional assessment
- C. understanding that the client should be advised to have the test repeated in three months
- D. understanding that anemia is a part of the degeneration of the bone marrow
Correct Answer: B
Rationale: Rationale: Answer B is correct because a hemoglobin level of 11mg/dl and hematocrit level of 32% in a 78-year-old client are indicative of anemia. Conducting a thorough nutritional assessment is essential to identify potential causes of anemia such as iron deficiency or vitamin deficiencies. This assessment will help determine appropriate interventions to manage the anemia.
Summary:
A: Incorrect. These levels are indicative of anemia, not normal findings.
C: Incorrect. Advising to repeat the test in three months may delay necessary interventions for the anemia.
D: Incorrect. While anemia can be related to bone marrow degeneration, a nutritional assessment is needed to identify the specific cause in this case.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This is the highest priority because compromised airway clearance can lead to life-threatening complications such as respiratory distress or hypoxia. Ensuring effective airway clearance is crucial in preventing respiratory compromise and maintaining oxygenation. Choices A, C, and D are not the highest priority because they do not directly address the immediate risk to the client's physiological well-being. Treating disturbed body image, anxiety, or imbalanced nutrition are important but can be addressed after ensuring the client's airway is clear and they are able to breathe effectively.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL
- B. Blood pressure of 90/50mmHg
- C. Pulse rate of 126 beats/min
- D. Urine output of more than 200mL/hour
Correct Answer: A
Rationale: The correct answer is A: Fluid intake of less than 2,500mL. In diabetes insipidus, the body cannot properly regulate fluid balance, leading to excessive thirst and urination. Successful treatment aims to manage these symptoms by reducing fluid intake to prevent dehydration. Therefore, a decrease in fluid intake indicates successful treatment.
Explanation for incorrect choices:
B: Blood pressure of 90/50mmHg - Blood pressure is not directly related to the treatment of diabetes insipidus.
C: Pulse rate of 126 beats/min - Pulse rate is not a specific indicator of successful treatment for diabetes insipidus.
D: Urine output of more than 200mL/hour - In diabetes insipidus, excessive urine output is a symptom of the condition, so an increase in urine output does not indicate successful treatment.
Which action best demonstrates the nurse’s role in ensuring continuity of care during the evaluation phase?
- A. Rewriting the care plan based on current findings.
- B. Communicating the client’s progress to the interdisciplinary team.
- C. Reassessing the client to gather additional data.
- D. Providing emotional support to the client and family.
Correct Answer: B
Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (D) is essential but may not specifically address continuity of care during evaluation.
Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
- A. Low fowler’s
- B. Modified trendelenburg
- C. Side lying
- D. Supine NERVOUS SYSTEM
Correct Answer: C
Rationale: The correct answer is C: Side lying position. This position helps prevent aspiration of secretions and promotes drainage from the mouth during and after a seizure. Placing the patient in a side lying position also helps prevent injury from falling and facilitates monitoring of the patient's airway.
Incorrect choices:
A: Low fowler's - This position does not provide optimal airway protection and may increase the risk of aspiration during a seizure.
B: Modified trendelenburg - This position may worsen the patient's airway patency and does not facilitate drainage of secretions.
D: Supine - Placing the patient in a supine position can lead to aspiration and compromise the airway, especially during a seizure.
Summary: The side lying position is the most appropriate choice as it ensures airway protection, facilitates drainage, and reduces the risk of aspiration during and after a seizure.