Nokea
A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: C
Rationale: The correct answer is C: Implementation. In this step of the nursing process, the nurse is carrying out the care plan based on the identified nursing diagnoses. The nurse is actively providing care and interventions to meet the patient's needs.
Assessment (A) is the initial step where data is collected and analyzed. Planning (B) is where goals and interventions are determined based on assessment findings. Evaluation (D) is the final step where the nurse assesses the effectiveness of the care provided.
In this scenario, the nurse has already completed the care plan and is now executing the plan by implementing the interventions, making choice C the correct answer.
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A client is admitted for a spelenectomy. What problem is the nurse aware that could develop?
- A. Infection
- B. Urinary retention
- C. Congestive heart failure
- D. Viral hepatitis
Correct Answer: A
Rationale: The correct answer is A: Infection. After a splenectomy, the client is at risk for infection due to the spleen's role in the immune system. Without the spleen, the body's ability to fight infections is reduced. Infections can be serious and life-threatening.
B: Urinary retention is not a typical complication of a splenectomy.
C: Congestive heart failure is not directly related to a splenectomy.
D: Viral hepatitis is not a common complication of a splenectomy.
The thymus gland role with the immune system is which of the following?
- A. Maturates B cells
- B. Maturates platelets
- C. Maturates red blood cells
- D. Maturates T cells
Correct Answer: D
Rationale: The correct answer is D: Maturates T cells. The thymus gland is crucial for the maturation of T cells, a type of white blood cell that plays a central role in the adaptive immune response. T cells mature in the thymus through a process of selection and education, where they learn to distinguish self from non-self antigens. This process is essential for the development of a functional immune system. Choices A, B, and C are incorrect because the thymus gland does not play a role in the maturation of B cells, platelets, or red blood cells, respectively.
A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, “This must be a mistake. No one in my family has ever had diabetes.” Based on this statement, the nurse suspects the client is using which coping mechanism?
- A. Denial
- B. Anger
- C. Withdrawal
- D. Resolution
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's refusal to accept the diagnosis of diabetes mellitus, stating that no one in their family has had it, indicates denial as a coping mechanism. Denial is a defense mechanism where individuals refuse to acknowledge unpleasant realities. In this case, the client is rejecting the diagnosis to avoid facing the reality of having a chronic condition. The other choices (B: Anger, C: Withdrawal, D: Resolution) do not fit the client's response in this scenario. Anger involves expressing frustration or hostility, withdrawal is avoiding the situation, and resolution is accepting and dealing with the issue.
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
- A. axilla
- B. upper arms
- C. elbows
- D. hands
Correct Answer: A
Rationale: The correct answer is A: axilla. When using crutches, weight should primarily be supported on the axilla to prevent nerve and blood vessel damage in the armpit area. Supporting weight on the upper arms (B) can lead to nerve compression and muscle strain. Supporting weight on the elbows (C) can cause nerve damage and discomfort. Supporting weight on the hands (D) can lead to hand and wrist pain and may not provide stable support. Therefore, the axilla is the most appropriate area to support weight while using crutches to ensure safety and comfort for the client.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently.
A: Completing questions in chronological order may not address the current problem effectively.
C: Making accurate interpretations of the data comes after data collection, not as the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.