Nokea
A patient presents with sudden-onset severe headache, altered mental status, and focal neurological deficits. Imaging reveals a hemorrhagic lesion within the right basal ganglia. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Ischemic stroke
- B. Subarachnoid hemorrhage
- C. Intracerebral hemorrhage
- D. Transient ischemic attack (TIA)
Correct Answer: C
Rationale: Intracerebral hemorrhage occurs when there is bleeding directly into the brain tissue, often due to conditions such as hypertension or vascular malformations. The sudden-onset severe headache, altered mental status, and focal neurological deficits described in the patient are typical symptoms of an intracerebral hemorrhage. The location of the hemorrhagic lesion within the right basal ganglia corresponds to the clinical presentation. Ischemic stroke, subarachnoid hemorrhage, and transient ischemic attack (TIA) typically have different presentations and imaging findings compared to an intracerebral hemorrhage. Therefore, in this scenario, intracerebral hemorrhage is the most likely cause of the patient's symptoms.
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Choose the step of nursing process that identiffies the famiilyy health seeking behavior.
- A. Assesment
- B. Planning
- C. Implementation
- D. Evaluation Situation
Correct Answer: A
Rationale: The step of the nursing process that identifies the family's health-seeking behavior is Assessment. During the assessment phase, the nurse gathers information about the family's health practices, beliefs, priorities, and past experiences related to seeking healthcare. This helps the nurse understand how the family approaches health and healthcare, which is crucial for providing tailored and effective care. By assessing the family's health-seeking behavior, the nurse can better collaborate with them to address their health needs and promote positive health outcomes.
What IMMEDIATE danger should the nurse anticipate post Transurethral Resection of the Prostate (TURP)?
- A. Infection
- B. Thrombosis
- C. Bleeding
- D. Shock
Correct Answer: C
Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.
A postpartum client who delivered a preterm infant expresses concerns about milk supply and worries about meeting the baby's nutritional needs. What nursing intervention should be prioritized to address the client's concerns?
- A. Providing education on techniques to enhance milk production and supply
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding until the infant reaches full term
- D. Referring the client to a dietitian for specialized nutritional support
Correct Answer: A
Rationale: Providing education on techniques to enhance milk production and supply should be prioritized to address the client's concerns about milk supply and meeting the baby's nutritional needs. By educating the client on proper breastfeeding techniques, frequent nursing sessions, skin-to-skin contact, and the importance of staying hydrated, the nurse can help promote successful breastfeeding and potentially increase milk production. Supplemental formula feedings are not the first line of intervention, as breastfeeding should be encouraged, especially for a preterm infant who may benefit significantly from breast milk. Encouraging the client to avoid breastfeeding until the infant reaches full term is not appropriate, as breastfeeding can still be beneficial for a preterm infant. Referring the client to a dietitian for specialized nutritional support may be beneficial, but addressing milk supply concerns through education should be prioritized initially to support breastfeeding success.
Nurse Mary had observedthat most patients with hypertension stop taking their medications and heard them saying "I feel good already" Which is the APPROPRIATE nursing diagnosis?
- A. Impaired gas exchange
- B. Knowledge deficit
- C. Anxiety
- D. Ineffective coping
Correct Answer: D
Rationale: The appropriate nursing diagnosis for this situation is "Ineffective coping" because the patients with hypertension who stop taking their medications despite feeling good may be using this behavior as a maladaptive coping mechanism. It suggests that they might not fully understand the importance of medication adherence or are struggling to accept their diagnosis. By not adhering to their prescribed treatment, they are putting themselves at risk for complications associated with uncontrolled hypertension. Therefore, the nursing diagnosis of "Ineffective coping" addresses the patients' inability to deal with their condition in a healthy manner, leading to noncompliance with their treatment regimen.
Patient Benito ask5 Nurse Virgo, "Why can't the surgeon just take out my pancreas?" The BEST response of Nurse Virgo is
- A. "your body needs to function well with your pancreas "
- B. "your attack will soon be overcome when you are at rest"
- C. "if your pancreas is removed, you can never eat fat and fried foods again"
- D. "antibiotic wil1 relieve signs of infection"
Correct Answer: A
Rationale: The best response of Nurse Virgo is to explain to Patient Benito that his body needs to function well with his pancreas. The pancreas plays a critical role in the digestive system by producing digestive enzymes and hormones that help regulate blood sugar levels. Removing the pancreas would result in serious health consequences and complications, as the body relies on it for essential functions. It is important for the patient to understand the significance of the pancreas and why its removal is not a viable solution.