Nokea
A nurse is preparing to assist with a magnetic resonance imaging (MRI) procedure for a patient. What action should the nurse prioritize to ensure procedural safety?
- A. Screening the patient for contraindications to MRI, such as metal implants or claustrophobia
- B. Administering intravenous sedation to the patient before the procedure
- C. Placing the patient in a supine position with arms at their sides during the MRI scan
- D. Allowing the patient to wear metallic jewelry or accessories during the procedure
Correct Answer: A
Rationale: The nurse should prioritize screening the patient for contraindications to MRI, such as metal implants or claustrophobia, to ensure procedural safety. Metallic objects can be hazardous in an MRI environment as they can be attracted to the magnet, potentially causing harm to the patient or staff. Claustrophobia can also be a significant issue for patients undergoing an MRI scan, and identifying this beforehand allows for appropriate measures to be taken to address the patient's anxiety or discomfort. Prioritizing this screening step helps ensure the safety and well-being of the patient during the MRI procedure.
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Which of the following actions is indicated in the management of a patient with an open chest wound (sucking chest wound)?
- A. Applying a sterile dressing and occlusive dressing.
- B. Administering supplemental oxygen.
- C. Providing reassurance and emotional support.
- D. Elevating the patient's legs to improve venous return.
Correct Answer: A
Rationale: An open chest wound, also known as a sucking chest wound, can lead to a collapsed lung and respiratory distress. Immediate management involves sealing the wound to prevent air from entering the pleural space and further compromising the patient's respiratory function. Applying a sterile dressing over the wound helps to prevent contamination and occluding the wound with an airtight covering, such as an occlusive dressing, can effectively reduce the risk of a tension pneumothorax, a serious complication that can arise from a sucking chest wound. These interventions help to stabilize the patient's condition and improve the chances of a successful recovery. Administering supplemental oxygen, though beneficial, would be secondary to the primary management of sealing the chest wound. Providing emotional support is important but addressing the physical emergency takes precedence. Elevating the patient's legs would not be appropriate in managing an open chest wound.
A patient presents with fever, chills, headache, and myalgia after returning from a camping trip. Laboratory tests reveal thrombocytopenia and leukopenia. Which of the following is the most likely causative agent?
- A. Plasmodium falciparum
- B. Trypanosoma cruzi
- C. Borrelia burgdorferi
- D. Leishmania donovani
Correct Answer: A
Rationale: The most likely causative agent in this scenario is Plasmodium falciparum, which is the parasite that causes malaria. The symptoms of fever, chills, headache, and myalgia following a camping trip are highly suggestive of malaria, especially if the patient has thrombocytopenia and leukopenia. Plasmodium falciparum is known to cause severe malaria with complications such as thrombocytopenia and leukopenia. The other options, Trypanosoma cruzi, Borrelia burgdorferi, and Leishmania donovani, do not typically present with all of the symptoms described and are not associated with the laboratory findings of thrombocytopenia and leukopenia.
Nursing diagnosis commonly used when working with Sandro is
- A. ineffective role performance
- B. Compromised family coping
- C. impaired social interaction
- D. risk for injury.
Correct Answer: C
Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.
A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the:
- A. Durable power of attorney
- B. Living will
- C. Informed consent
- D. Advance directives
Correct Answer: B
Rationale: A living will is a legal document that allows an individual to express their wishes regarding medical treatment in the event they become unable to make decisions. It specifically outlines the medical treatments a person chooses to refuse or accept under certain circumstances. It is important to differentiate a living will from a durable power of attorney, which designates someone to make healthcare decisions on behalf of the individual when they are unable to do so, and advance directives, which encompass both a living will and a durable power of attorney for healthcare. The living will serves as a guide for healthcare professionals and family members to honor the individual's preferences for medical care.
Which of the following statements is TRUE?
- A. History taking must be long regardless if the child appears to be well
- B. No proper history can be obtained without observation of the child and the mother.
- C. Nurse Nanie should refrain from asking about the illness of other members of the family.
- D. An example of what can be elicited from a social history is how the disease started.
Correct Answer: D
Rationale: An example of what can be elicited from a social history is how the disease started. This statement is true because a social history typically includes information about factors such as the onset of the illness, the child's living environment, family dynamics, and any recent events that may have contributed to the child's current condition. Understanding how the disease started can provide valuable insights into possible triggers or underlying causes, helping healthcare providers develop an appropriate treatment plan. A comprehensive social history is essential for providing holistic care to the child and addressing all relevant factors that may impact their health and well-being.