Nokea
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.
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A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a cerebellar brain tumor can affect the client's coordination and balance due to its location in the brain responsible for fine motor movements. Impaired balance increases the risk for falls and injuries. Visual field deficits (choice A) may contribute to the risk of injury but not as directly as impaired balance. Difficulty swallowing (choice C) and psychomotor seizures (choice D) are not directly related to the client's risk for injury due to a cerebellar brain tumor.
A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:
- A. Lie supine with his neck extended
- B. Sit upright, leaning slightly forward
- C. Blow his nose and then put lateral pressure on his nose
- D. Hold his nose while bending forward at the waist
Correct Answer: B
Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration.
A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis.
C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding.
D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.
Which of the following parts of neuron transmits impulses away from the cell body?
- A. Dendrite
- B. . Neurolemma
- C. Axon
- D. Synapse
Correct Answer: C
Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals.
Rationale:
1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect.
2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect.
3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.
The nursing care for the client in addisonian crisis should include which of the following interventions?
- A. Encouraging independence with activities of daily living (ADL)
- B. Allowing ambulation as tolerated
- C. Offering extra blankets and raising the heat in the room to keep the client warm
- D. Placing the client in a private room
Correct Answer: C
Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate neurological, musculoskeletal, or sensory issues affecting mobility. Speech (B) is related to communication, judgment (C) to decision-making, and endurance (D) to stamina, not specifically to loss of ability. Balance is crucial for mobility and overall function, making it a priority area for assessment in healthcare settings.