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A patient had a lumbar injury. Which neurological test by the nurse would be affected?
- A. Rhine’s test
- B. Pupillary reaction
- C. Romberg’s test
- D. Patellar reflex
Correct Answer: C
Rationale: The correct answer is C: Romberg’s test. Romberg’s test assesses a patient's ability to maintain balance with eyes closed, relying on proprioception from the lower limbs. A lumbar injury can affect proprioception, leading to impaired balance. Rhine’s test evaluates auditory function, not affected by a lumbar injury. Pupillary reaction assesses cranial nerve function, unrelated to a lumbar injury. The patellar reflex is a deep tendon reflex, primarily involving the spinal cord segments L2-L4, not directly affected by a lumbar injury.
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The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning findings such as abnormal kidney function, lack of voiding, and decreased oral intake, the nurse needs to move to the diagnosis step of the nursing process. This involves analyzing the data collected to identify the patient's health problems and risks. In this case, the nurse needs to determine potential underlying issues related to the kidney function abnormalities and lack of voiding, and formulate a nursing diagnosis based on the findings.
Summary of other choices:
B: Planning comes after diagnosis and involves setting goals and creating a plan of care.
C: Implementation follows planning and involves carrying out the plan of care.
D: Evaluation is the final step of the nursing process where the nurse assesses the effectiveness of the interventions implemented.
A client who underwent litholapaxy surgery for removing bladder stones wants to know how long the urethral catheter needs to stay in place. Which of the ff is the correct response?
- A. The catheter should remain in place for 7 days
- B. The catheter should remain in place for 1-2 days
- C. The catheter should remain in place for 2-3 days
- D. The catheter should remain in place for 3-4 days
Correct Answer: B
Rationale: The correct answer is B: The catheter should remain in place for 1-2 days. After litholapaxy surgery, the urethral catheter is typically removed within 1-2 days to prevent infection and promote healing. Keeping the catheter in place for too long can increase the risk of complications such as urinary tract infections. Options A, C, and D suggest longer durations which are not necessary and may lead to unnecessary discomfort and risks for the client. Therefore, the optimal timeframe for catheter removal post-litholapaxy surgery is within 1-2 days.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking the beta receptors in the heart, which reduces the heart's workload and oxygen demand, making it an effective treatment for angina. By blocking beta stimulation, propranolol helps to decrease heart rate, blood pressure, and myocardial contractility. This ultimately improves oxygen supply to the heart muscle.
Explanation for other choices:
A: Act as a vasoconstrictor - Propranolol does not act as a vasoconstrictor; it actually can cause vasodilation in some cases.
C: Act as a vasodilator - Propranolol is not primarily a vasodilator; its main action is to block beta stimulation in the heart.
D: Increase the heart rate - Propranolol actually decreases heart rate by blocking beta receptors in the heart.
In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:
- A. Accepting the denial.
- B. Supporting the denial.
- C. Confronting the denial.
- D. Interpreting the denial.
Correct Answer: C
Rationale: The correct response is C: Confronting the denial. Denial is a defense mechanism that can hinder the client's acceptance and coping with the situation. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and process their feelings. Accepting (A) or supporting (B) the denial would enable the client to avoid facing reality. Interpreting (D) the denial may lead to miscommunication or misunderstanding. Confronting the denial encourages the client to address their emotions and move towards acceptance and healing.
The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
- A. increasing saturated fat intake and fasting in the afternoon.
- B. increasing intake of vitamins B and D and taking iron supplements.
- C. eating a candy bar if light-headedness occurs.
- D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D
Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.