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A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition.
Incorrect choices:
A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it.
B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed.
D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.
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The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
- A. Elevated serum acetone level
- B. Serum alkalosis
- C. Serum ketone bodies
- D. Below-normal serum potassium level
Correct Answer: D
Rationale: Step 1: In HHNS, there is severe hyperglycemia leading to osmotic diuresis.
Step 2: Osmotic diuresis causes loss of potassium in urine, leading to hypokalemia.
Step 3: Hypokalemia is a common electrolyte imbalance in HHNS due to excessive urinary loss of potassium.
Step 4: Therefore, the nurse should anticipate a below-normal serum potassium level in a client with HHNS.
Summary:
A: Elevated serum acetone level is seen in diabetic ketoacidosis, not HHNS.
B: Serum alkalosis is not typically associated with HHNS.
C: Serum ketone bodies are elevated in diabetic ketoacidosis, not HHNS.
A client with Hashimoto’s thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client’s cardiac history, the nurse would expect that the client’s initial dose for the thyroid replacement would be which of the following?
- A. 25 g/day, initially
- B. Delayed until after thyroid surgery
- C. 100 g/day, initially
- D. Initiated before thyroid surgery
Correct Answer: A
Rationale: The correct answer is A: 25 g/day, initially. In this scenario, the client with Hashimoto's thyroiditis and a history of cardiac issues requires a cautious approach due to the risk of exacerbating cardiac conditions with thyroid hormone replacement. Starting with a low dose of 25 µg/day allows for careful monitoring of the client's response and prevents potential adverse effects on the cardiovascular system.
Summary:
B: Delayed until after thyroid surgery - Not appropriate as the client requires thyroid replacement therapy for Hashimoto's thyroiditis.
C: 100 µg/day, initially - Too high of an initial dose and may lead to adverse cardiovascular effects.
D: Initiated before thyroid surgery - Not relevant to the client's situation as there is no indication for thyroid surgery mentioned in the question.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation.
Incorrect Choices:
A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns.
C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication.
D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
- A. Placement of IV and central venous pressure lines
- B. Administrating cleansing enemas
- C. Observing for leakage of urine or stool from the anastomosis
- D. Assessing the clients ability to manage self catheterization
Correct Answer: C
Rationale: The correct answer is C: Observing for leakage of urine or stool from the anastomosis. This is crucial in nursing management post-urinary diversion procedure to prevent complications such as infection, dehydration, and skin breakdown. Leakage can indicate issues with the surgical site integrity and requires prompt intervention.
A: Placement of IV and central venous pressure lines is important but not as critical as monitoring for leakage from the anastomosis.
B: Administering cleansing enemas may be necessary for certain procedures but is not the most important factor in this case.
D: Assessing the client's ability to manage self-catheterization is important for long-term care but does not take precedence over monitoring for potential complications like leakage.
In summary, option C is the most important factor as it directly impacts the client's immediate post-operative care and helps prevent serious complications.
Three days after admission Ms. CC continued to have frequent stools. Her oral intake of both fluids and solids are poor. Her physician ordered parenteral hyperalimentation. Hyperalimentation solutions are:
- A. Hypotonic solutions used primarily to increase osmotic pressure of blood plasma
- B. Hypertonic solutions used primarily for hydration when hemoconcentration is present
- C. Alkalizing solutions used to treat metabolic acidosis thus reducing cellular sweating
- D. Hyperosmolar solutions used primarily to reverse negative nitrogen balance
Correct Answer: D
Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance.
Rationale:
1. Hyperalimentation solutions are designed to provide essential nutrients intravenously.
2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition.
3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake.
4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance.
Summary:
A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it.
B: Hypertonic solutions are not primarily used for hydration in this context.
C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.