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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 prioritizes the patient's immediate concerns to address them effectively. By focusing on the presenting situation first, the nurse can gather relevant data and identify key issues. This step ensures that the nurse addresses the most pressing problems promptly.
A: Completing questions in chronological order may not be necessary and could delay addressing the immediate concern.
C: Making accurate interpretations of data should come after gathering relevant information about the presenting situation.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific data.
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Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: The correct answer is D: high calorie high protein. In COPD exacerbation, the body requires extra calories and protein for energy and muscle strength. High-calorie foods help combat weight loss and fatigue. High-protein foods aid in muscle repair and maintenance. Low-fat low-cholesterol (A) is not ideal as healthy fats are needed. Low-sodium (B) is not necessary unless there is concurrent heart failure. Bland soft diet (C) is not suitable as it does not provide enough calories and protein needed for COPD exacerbation.
Which part of the body is supplied by nerves form the thoracic cord?
- A. Head
- B. Pelvis
- C. Trunk
- D. Coccyx
Correct Answer: C
Rationale: The correct answer is C: Trunk. The thoracic cord supplies nerves to the trunk region of the body. The thoracic spinal nerves innervate the chest, abdomen, and back. They control sensation and movement in these areas. The head (A) is mainly supplied by cranial nerves, the pelvis (B) is innervated by lumbar and sacral nerves, and the coccyx (D) is supplied by the sacral nerves. Therefore, the correct answer is C as it aligns with the anatomical distribution of the thoracic spinal nerves.
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.
A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery-this will go away on its own”. In considering her response to the client, the nurse must depend on the ethical principle of:
- A. Beneficence
- B. Advocacy
- C. Autonomy
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.
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 because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery.
A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs.
B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role.
C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.