Nokea
A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
- A. Risk for impaired skin integrity
- B. Risk for infection
- C. Spiritual distress
- D. Reflex urinary incontinence
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.
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An elderly patient, Mr. Cruz is being cared for by nurse Bennie because of pulmonary embolism. Nurse Bennie would anticipate an order for immediate administration of:
- A. warfarin
- B. heparin
- C. dexamethazone
- D. protamine sulfate
Correct Answer: B
Rationale: The correct answer is B: heparin. Heparin is an anticoagulant used for immediate treatment of pulmonary embolism to prevent further clot formation. It acts quickly by inhibiting clotting factors. Warfarin (A) is used for long-term anticoagulation but has a slower onset. Dexamethasone (C) is a corticosteroid used for inflammation, not thrombosis. Protamine sulfate (D) is used to reverse the effects of heparin but is not indicated for initial treatment.
Which of the following is not a criterion for a valid informed consent that a nurse should identify?
- A. freely given
- B. with coercion
- C. has an explanation of procedures
- D. describes the alternatives
Correct Answer: B
Rationale: The correct answer is B: with coercion. Informed consent must be freely given without any form of coercion to ensure the individual's autonomy and decision-making capacity. Coercion can lead to involuntary consent, undermining the principle of respect for autonomy. Choices A, C, and D are all criteria for valid informed consent. Choice A ensures the individual is voluntarily agreeing without any external pressure. Choice C ensures the individual understands the procedures involved, promoting transparency. Choice D ensures the individual is aware of alternative options, allowing for an informed decision-making process.
When caring for Mr. Reyes, the nurse should assess for
- A. Decreased carotid pulses
- B. Altered level of consciousness
- C. Bleeding from oral cavity
- D. Absence of deep tendon-reflexes
Correct Answer: B
Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention.
A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status.
C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status.
D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.
Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
- A. 10% dextrose and saline
- B. 5% dextrose and water
- C. 5% dextrose and water with 60 mEq
- D. Distilled water KCl
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow’s hierarchy of basic human needs, is appropriate for what level of needs?
- A. Physiologic
- B. Safety
- C. Love and belonging
- D. Self-actualization
Correct Answer: A
Rationale: The correct answer is A: Physiologic. Impaired Gas Exchange pertains to the basic physiological need for oxygenation, which is fundamental for survival. Maslow's hierarchy states that physiological needs are the most fundamental and must be met before progressing to higher-level needs. Safety, love and belonging, and self-actualization are higher-level needs compared to physiological needs. Therefore, Impaired Gas Exchange aligns with the physiological level of needs in Maslow's hierarchy.