Nokea
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 most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.
You may also like to solve these questions
As the surgical incision is closed, who are the personnel in-charge in counting the needles, sponges, and instruments?
- A. the surgeon and anesthesiologist
- B. the surgeon and the registered
- C. the circulating and scrub nurse nurse first assistant
- D. the anesthesiologist and anesthetist
Correct Answer: C
Rationale: The correct answer is C - the circulating and scrub nurse first assistant. The circulating nurse is responsible for counting needles, sponges, and instruments during the closing of the surgical incision to ensure nothing is left inside the patient. The scrub nurse first assistant also plays a crucial role in this process by assisting in the counting and keeping track of the items used during the procedure. The other choices are incorrect because the surgeon and anesthesiologist (A) are not typically involved in counting items during the surgical closure, the surgeon and the registered (B) may not have the necessary training for accurate counting, and the anesthesiologist and anesthetist (D) are not directly involved in the surgical closing process.
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
- A. Unequal growth of fingers and toes.
- B. Purplish discoloration of hands and feet.
- C. Webbing between fingers and toes.
- D. Deformities of the wrists and ankles.
Correct Answer: B
Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.
Bell’s palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
- A. 3rd
- B. 7th
- C. 5th
- D. 8th
Correct Answer: B
Rationale: The correct answer is B: 7th cranial nerve. Bell's palsy is caused by inflammation of the facial nerve (7th cranial nerve), leading to facial muscle weakness or paralysis. The 3rd cranial nerve (choice A) controls eye movement, the 5th cranial nerve (choice C) is responsible for facial sensation and chewing, and the 8th cranial nerve (choice D) is related to hearing and balance. Bell's palsy specifically affects the facial muscles, making choice B the correct answer.
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity.
2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin.
3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects.
4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity.
Summary:
A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function.
B: Hyponatremia does not directly predispose to digoxin toxicity.
C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects.
D: Hypernatremia is not directly related to digoxin toxicity.
Which of the ff is the best dietary advice to maximize the immune function in healthy people?
- A. Include immune enhancing formulas
- B. Avoid polyunsaturated fatty acids
- C. Increase intake of essential fatty acids and omega 3 fatty acids
- D. Follow a balanced and varied diet CARING FOR CLIENT WITH IMMUNE MEDIATED DISORDERS
Correct Answer: D
Rationale: Step-by-step rationale:
1. A balanced and varied diet provides essential nutrients for immune function.
2. Including a wide range of foods ensures intake of vitamins, minerals, and antioxidants crucial for immune health.
3. Avoiding extremes like excessive immune-enhancing formulas or eliminating polyunsaturated fatty acids maintains balance.
4. Essential fatty acids and omega-3 fatty acids are beneficial but should be part of a well-rounded diet.
5. For clients with immune-mediated disorders, individualized dietary advice may be necessary.
Summary:
- A: Immune-enhancing formulas may not be necessary and could disrupt balance.
- B: Avoiding all polyunsaturated fatty acids is not advisable as some are essential for health.
- C: Increasing essential fatty acids is beneficial but should be part of a balanced diet.