A nurse is formulating a clinical question for evidence-based practice. Place in order the steps the nurse should use to clarify the scope of the problem and clinical topic of interest. Begin with the first step of the process and proceed ordering the steps ending with the final step of the process. Provide answer as lowercase letters separated by commas (e.g., a, b, c, d, e).
- A. Intervention
- B. Outcome
- C. Population
- D. Time
Correct Answer: c
Rationale: Population : The first step is to clearly define the population of interest for the clinical question. Identifying the specific population will help in formulating a focused and relevant question.
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A 45-year old female diabetic is displaying signs of irritability and irrational behavior during an office visit. The nurse observes visible tremors in the client's hands. based on the client's history and the nurse's understanding of diabetes mellitus, the nurse interprets these findings to be signs of:
- A. hyperglycemia
- B. hyperglycemic hyperosmolar
- C. diabetic ketoacidosis (DKA) nonketosis (HHNK)
- D. hypoglycemia
Correct Answer: D
Rationale: The signs of irritability, irrational behavior, and visible tremors in the hands observed in the 45-year old female diabetic suggest hypoglycemia. Hypoglycemia occurs when blood sugar levels drop below normal levels, causing the body and brain to receive inadequate fuel. This leads to symptoms like irritability, irrational behavior, and tremors, which are signs of the brain not receiving enough glucose for proper functioning. In diabetic patients, particularly those on medications like insulin or certain oral hypoglycemic agents, hypoglycemia can occur if they take too much medication, skip meals, or engage in excessive physical activity without adjusting their treatment regimen. Immediate treatment for hypoglycemia usually involves consuming a rapid source of sugar, such as glucose tablets, juice, or candy, to quickly raise blood sugar levels back to normal range.
An appropriate nursing action to include in the care of an infant with congenital heart disease who has been admitted with heart failure is:
- A. Positioning flat on the back
- B. Encouraging nutritional fluids
- C. Offering small frequent feedings
- D. Measuring the head circumference
Correct Answer: C
Rationale: Infants with congenital heart disease who have been admitted with heart failure may have difficulty feeding due to increased work of breathing and poor energy reserves. Offering small, frequent feedings can help prevent fatigue and provide adequate nutrition to support the infant's growth and recovery. It also helps to prevent overloading the heart with a large volume of fluids at once. This approach allows the infant to receive enough calories while reducing the risk of aspiration and conserving energy for feeding and breathing. Positioning the infant flat on the back may worsen respiratory distress, encouraging nutritional fluids alone may not address the feeding challenges faced by the infant, and measuring the head circumference is important for growth monitoring but may not be the priority when managing heart failure in this case.
In planning an educational session for a patient with HIV, the nurse would include which of the following as a method of transmission for HIV? i.Saliva iv.Semen ii.Tears v.Blood iii.Breast milk
- A. 1, 4, 2005
- B. 1, 2, 4, 5
- C. 3, 4, 2005
- D. All of the above
Correct Answer: C
Rationale: HIV can be transmitted through specific body fluids that contain the virus. Saliva, tears, and semen do not typically contain enough HIV to transmit the virus, so they are not considered significant modes of transmission. However, blood, breast milk, and genital fluids (such as semen) are known to contain higher levels of HIV and can lead to transmission of the virus. Therefore, the nurse would include blood, breast milk, and semen as methods of transmission for HIV during the educational session.
Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:
- A. 48 hours
- B. 2 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: Compartment syndrome is a serious condition that results from increased pressure within a closed anatomical space (compartment), leading to decreased circulation to local neuromuscular structures. In the case of a casted elbow, if compartment syndrome is left untreated and persists for more than 24 hours, irreversible damage can occur. This is due to the compromised blood flow causing tissue ischemia, which can lead to permanent nerve and muscle damage. Therefore, it is crucial for healthcare providers to monitor for signs and symptoms of compartment syndrome and intervene promptly to prevent long-term complications.
The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
- A. The nurse should insert a padded tongue blade in the patient's mouth to prevent the child from swallowing or choking on his tongue.
- B. The nurse should help the mother restrain the child to prevent him from injuring himself.
- C. The nurse should call the operator to page for seizure assistance.
- D. The nurse should clear the area and position the client safely.
Correct Answer: D
Rationale: In this situation, the nurse's priority is to provide a safe environment for the patient during the seizure. Inserting a padded tongue blade (Option A) is not recommended as it can cause more harm than good, such as dental injury. Restraint of the patient (Option B) during a seizure is also not recommended as it can lead to injury. Calling the operator to page for seizure assistance (Option C) may delay immediate intervention. The best course of action is for the nurse to clear the area of any objects that may injure the patient during the seizure and position the client safely. This will help prevent injury and ensure the patient's safety until the seizure subsides.