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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. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care.
Incorrect choices:
A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.
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The nurse knows which of the following is true about immunity?
- A. Antibody-mediated defense occurs through the T-cell system
- B. Cellular immunity is mediated by antibodies produced by the B-cells
- C. Antibodies are produced by the B-cells
- D. Lymphocytes increase with an allergic response
Correct Answer: C
Rationale: Rationale:
Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens.
Incorrect Choices:
A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity.
B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells.
D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.
A 27-year old adult is admitted for treatment of Crohn’s disease. Which information is most significant when the nurse assesses nutritional health?
- A. Anthropometric measurements
- B. dry skin
- C. bleeding gums
- D. facialrubor
Correct Answer: A
Rationale: The correct answer is A: Anthropometric measurements. This includes height, weight, and body mass index, which are crucial indicators of the nutritional status of a patient with Crohn's disease. It helps assess malnutrition, muscle wasting, and overall nutritional health. Dry skin (B), bleeding gums (C), and facial rubor (D) are not direct indicators of nutritional health in a patient with Crohn's disease. Dry skin may indicate dehydration, bleeding gums may suggest poor oral hygiene or gum disease, and facial rubor may be a sign of inflammation but are not specific to nutritional status.
Which of the ff interventions is implemented for a client with empyema?
- A. Teach the client breathing exercises
- B. Offer assurance that empyema takes less time to resolve
- C. Recommend that the client eat a balanced but light diet
- D. Emphasize the completion of the entire course of drug therapy
Correct Answer: D
Rationale: The correct answer is D: Emphasize the completion of the entire course of drug therapy. Empyema is a serious condition that requires antibiotic treatment. Emphasizing the completion of the entire course of drug therapy is crucial to ensure that the infection is completely eradicated and to prevent the development of drug-resistant strains. Teaching breathing exercises (choice A) may help improve lung function but is not the primary intervention for empyema. Offering assurance that empyema takes less time to resolve (choice B) is incorrect as it can mislead the client about the seriousness of the condition. Recommending a balanced but light diet (choice C) may be beneficial for overall health but is not directly related to treating empyema.
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.
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
- A. To form a language that can be encoded only by nurses
- B. To distinguish the nurse’s role from the physician’s role
- C. To develop clinical judgment based on other’s intuition
- D. To help nurses focus on the scope of medical practice
Correct Answer: D
Rationale: The correct answer is D: To help nurses focus on the scope of medical practice. Developing a standard formal nursing diagnosis helps nurses to identify and focus on the patient's specific health issues within the nursing scope of practice. This enables nurses to provide targeted and effective care interventions.
A: To form a language that can be encoded only by nurses - This choice is incorrect because the purpose of a nursing diagnosis is not exclusive to nurses and should be comprehensible to all healthcare professionals caring for the patient.
B: To distinguish the nurse’s role from the physician’s role - While this distinction is important, the main purpose of developing a nursing diagnosis is to guide nursing interventions based on the patient's nursing care needs, rather than solely differentiating roles.
C: To develop clinical judgment based on other’s intuition - This choice is incorrect as clinical judgment should be based on evidence-based practice and critical thinking, rather than solely relying on intuition or others' opinions.