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: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.
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The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise this part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. Collaborative problems are issues that require both medical and nursing interventions, whereas nursing diagnoses are within the scope of nursing practice. The etiology identifies the cause of the problem (tibial fracture), the nursing diagnosis states the problem (impaired physical mobility), and the defining characteristic is the evidence that supports the diagnosis (inability to ambulate). Therefore, the nurse should revise the part stating collaborative problem as it does not align with the nature of the issue presented in the scenario.
Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
- A. 2-5 mmHg
- B. 10-15 mmHg
- C. 5-10 mmHg
- D. 20-25 mmHg
Correct Answer: B
Rationale: The correct answer is B (10-15 mmHg) because this range is considered safe and effective for suctioning in most cases. Lower suction pressures (such as 2-5 mmHg) may not effectively clear secretions, while higher pressures (20-25 mmHg) can cause tissue damage. Choice C (5-10 mmHg) falls within the safe range but may not provide enough suction for effective clearance. Therefore, the optimal suction pressure for James using the portable suction unit at home is 10-15 mmHg.
A nurse is working with a dying client and his family. Which communication technique is most important to use?
- A. Reflection
- B. Clarification
- C. Interpretation
- D. Active listening
Correct Answer: D
Rationale: The correct answer is D: Active listening. Active listening is crucial when working with a dying client and their family as it involves fully concentrating, understanding, responding, and remembering what is being said. This technique helps the nurse show empathy, build trust, and provide emotional support. By actively listening, the nurse can better understand the client's needs and concerns, which is essential in end-of-life care. Reflection (A) involves paraphrasing what the client said, which may not always be appropriate in this sensitive situation. Clarification (B) and Interpretation (C) involve adding one's own understanding or perspective, which can be intrusive and may not align with the client's feelings or beliefs.
Which of the ff is a sign or symptom characteristic of the later stages of TB?
- A. Fatigue
- B. Anorexia
- C. Hemoptysis
- D. Weight loss
Correct Answer: C
Rationale: The correct answer is C: Hemoptysis. In the later stages of TB, the infection can lead to damage in the lungs, causing blood to be coughed up (hemoptysis). This is a serious symptom indicating advanced disease progression. Fatigue (A), anorexia (B), and weight loss (D) are common symptoms of TB but can occur in earlier stages as well. Hemoptysis specifically indicates more severe lung involvement, making it characteristic of later stages.
A client hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which of the following instructions would be most important to include in the client’s teaching plan?
- A. maintain a moderate exercise
- B. Lose weight
- C. Jog at least 2 miles per day
- D. Rest as much as possible
Correct Answer: A
Rationale: The correct answer is A: maintain a moderate exercise. Exercise helps in maintaining bone density, which is crucial in managing hyperparathyroidism. Moderate exercise can also help in weight management and overall health. Choice B, losing weight, can be helpful but not as crucial as exercise. Choice C, jogging 2 miles per day, may be excessive for some individuals and not necessary for managing hyperparathyroidism. Choice D, resting as much as possible, is not recommended as it can lead to muscle weakness and bone loss, which are already concerns in hyperparathyroidism.