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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. 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.
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Which of the ff. medications might be ordered to help control symptoms of multiple sclerosis, and possibly induce a remission?
- A. Acyclovir
- B. Thyrotropin
- C. ACTH
- D. Benadryl
Correct Answer: C
Rationale: Correct Answer: C - ACTH
Rationale:
1. ACTH (adrenocorticotropic hormone) can help control symptoms and induce remission in multiple sclerosis by reducing inflammation.
2. ACTH stimulates the production of cortisol, a natural anti-inflammatory hormone.
3. By reducing inflammation in the central nervous system, ACTH can help manage symptoms and promote remission.
Summary of other choices:
A: Acyclovir - Antiviral medication used to treat herpes infections, not effective for multiple sclerosis.
B: Thyrotropin - Hormone that stimulates thyroid function, not used in the treatment of multiple sclerosis.
D: Benadryl - Antihistamine used for allergies and itching, not indicated for multiple sclerosis management.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:
- A. Provide clear liquids only until the patient can swallow solid foods.
- B. Have the patient swallow twice after each bite
- C. Place food on the unaffected side of the patient’s mouth
- D. Check if the patient’s mouth for pocketing of food
Correct Answer: A
Rationale: The correct answer is A because providing clear liquids only until the patient can swallow solid foods is not a recommended nursing intervention to prevent aspiration. Clear liquids do not require the same level of swallowing coordination as solid foods, so it may not help improve swallowing ability.
B: Having the patient swallow twice after each bite can help clear the throat and reduce the risk of aspiration.
C: Placing food on the unaffected side of the mouth can help direct the food towards the stronger side for swallowing.
D: Checking the patient's mouth for pocketing of food is important to ensure that food is not being retained in the mouth, which could lead to aspiration.
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 because focusing on the patient's presenting situation is the first step in the problem-oriented approach. This allows the nurse to gather relevant data related to the current health issue, which is crucial for identifying the problem and formulating a care plan. Option A is incorrect as chronological order may not prioritize the most critical data. Option C is incorrect as interpretations come after data collection. Option D is incorrect as observation typically follows data collection and analysis. Focusing on the patient's presenting situation ensures efficient and effective data collection for problem-solving.
A patient has iron deficiency anemia. Which of the following foods will best help provide dietary iron?
- A. Fresh fruits
- B. Dairy products
- C. Lean red meats
- D. Breads and cereals
Correct Answer: C
Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.