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A nurse teaches a client newly diagnosed with diabetes how to administer insulin. What type of nursing intervention is this?
- A. Independent intervention
- B. Dependent intervention
- C. Interdependent intervention
- D. Collaborative intervention
Correct Answer: A
Rationale: Correct Answer: A (Independent intervention)
Rationale:
1. Independent interventions are actions that nurses can initiate without a doctor's order.
2. Teaching a client how to administer insulin falls under the scope of nursing practice.
3. Nurses have the knowledge and authority to educate clients on self-care management.
4. This intervention does not require collaboration with other healthcare providers.
Summary:
B: Dependent interventions require a doctor's order.
C: Interdependent interventions involve collaboration with other healthcare providers.
D: Collaborative interventions involve working with other healthcare professionals.
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A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The correct answer is C: Acute pain. This is the most pertinent nursing diagnosis because the patient has a right femur fracture and reports moderate discomfort. The priority is to address the acute pain associated with the fracture. Posttrauma syndrome (A) typically involves a broader range of emotional and psychological responses beyond just moderate discomfort. Constipation (B) is not the priority in this case, as it is not directly related to the patient's current condition. Anxiety (D) may be present but addressing the acute pain takes precedence in this situation to ensure the patient's comfort and well-being.
A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
- A. The patient will ambulate in hallways.
- B. The nurse will monitor the patient’s heart rhythm continuously this shift. The patient will feed self at all mealtimes today without reports of shortness of
- C. breath. The nurse will administer pain medication every 4 hours to keep the patient free from
- D. discomfort.
Correct Answer: B
Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.
When caring for a client, whose being treated for hyperthyroidism, it’s important to:
- A. Provide extra blankets and clothing to keep the client warm.
- B. Monitor the client for signs of restlessness, sweating and excessive weight loss during thyroid replacement therapy.
- C. Balance the client’s periods of activity and rest.
- D. Encourage the client to be active to prevent constipation.
Correct Answer: B
Rationale: The correct answer is B. Monitoring for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy is essential in managing hyperthyroidism. Restlessness can indicate increased metabolic rate, sweating can be due to excessive heat production, and weight loss can be a sign of overactive thyroid function. Providing extra blankets (Choice A) may worsen symptoms of heat intolerance. Balancing activity and rest (Choice C) is important, but not specific to hyperthyroidism. Encouraging activity to prevent constipation (Choice D) is not directly related to managing hyperthyroidism.
Cancer is the second major cause of death in this country. What is the first step toward effective cancer control?
- A. Increasing governmental control of potential carcinogens
- B. Changing habits and customs that predispose the individual to cancer
- C. Conducting more mass screening programs
- D. Educating public and professional people about cancer
Correct Answer: B
Rationale: The correct answer is B because changing habits and customs that predispose the individual to cancer is crucial in preventing cancer. This includes lifestyle changes such as quitting smoking, maintaining a healthy diet, exercising regularly, and avoiding excessive sun exposure. By modifying behaviors that increase cancer risk, individuals can significantly reduce their chances of developing cancer.
A: Increasing governmental control of potential carcinogens is not the first step towards effective cancer control as individual behaviors have a more direct impact on cancer risk.
C: Conducting more mass screening programs is important but not the first step as prevention through lifestyle changes takes priority.
D: Educating the public and professionals about cancer is essential but changing habits is the initial crucial step in effective cancer control.