Nokea
A patient with peripheral vascular disease is receiving discharge instructions. Which of the following information should be included?
- A. Walk barefoot whenever possible.
- B. Use a heating pad to keep feet warm.
- C. Avoid crossing the legs.
- D. Use antibacterial ointment to treat skin lesions prone to infection.
Correct Answer: C
Rationale: Patients with peripheral vascular disease should be advised to avoid crossing their legs as this can impede blood flow. Peripheral vascular disease, also known as arteriosclerosis obliterans, is primarily caused by atherosclerosis. Atherosclerosis results in the gradual progression of arterial occlusion due to the formation of atheromas. Crossed legs can further restrict blood flow, exacerbating the condition. Walking barefoot should be discouraged to prevent potential injuries to the feet. Using a heating pad can lead to burns and should be avoided to prevent thermal injuries. While using antibacterial ointment for skin lesions may be beneficial, it is not the priority instruction for patients with peripheral vascular disease.
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A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
- A. An adolescent male
- B. An elderly woman
- C. A young woman
- D. An elderly man
Correct Answer: C
Rationale: The correct answer is 'A young woman.' Raynaud's disease is most common in young women and is often associated with rheumatologic disorders like lupus and rheumatoid arthritis. This disorder involves vasospasm of the arteries, leading to reduced blood flow to the fingers and toes. Typically, Raynaud's affects the fingers, and in some cases, it can affect the toes. Only rarely does it involve other body parts such as the nose, ears, nipples, and lips. Choices B, C, and D are less likely as Raynaud's disease predominantly affects young women, although it can occur in other demographic groups as well.
Which of the following is an example of intragroup conflict?
- A. A nurse writes a grant for a non-profit organization to raise money for advertising
- B. Members of a multidisciplinary team cannot agree on the best course of action for a client
- C. A client does not receive his medication on time because the nurse was on break
- D. A nurse feels frustrated that her employer does not provide on-site child care
Correct Answer: B
Rationale: Intragroup conflict refers to disagreements within a group. The correct answer, 'Members of a multidisciplinary team cannot agree on the best course of action for a client,' exemplifies this type of conflict well. In this scenario, professionals within the same team are unable to reach a consensus on how to proceed with client care. Choices A, C, and D do not reflect intragroup conflict. Writing a grant for a non-profit organization, a client not receiving medication due to a nurse's break, and a nurse feeling frustrated about the lack of on-site child care do not involve conflicts within a group of professionals.
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
- A. Altered tissue perfusion
- B. Risk for fluid volume deficit
- C. High risk for hemorrhage
- D. Risk for infection
Correct Answer: D
Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.
A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?
- A. Small blue-white spots are visible on the oral mucosa.
- B. The rash begins on the trunk and spreads outward.
- C. There is low-grade fever.
- D. The lesions have a "teardrop-on-a-rose-petal"? appearance.
Correct Answer: A
Rationale: The presence of small blue-white spots on the oral mucosa, known as Koplik's spots, is characteristic of measles (rubeola) infection. These spots typically appear on the buccal mucosa opposite the second molars, 1-2 days before the rash onset, and last until 2 days after the rash appears. While Koplik's spots are pathognomonic for measles, their absence does not rule out the diagnosis. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because the rash pattern, presence of low-grade fever, and characteristic appearance of lesions are not specific indicators of measles infection.
Which action represents the evaluation stage of the plan of care?
- A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
- B. The nurse assesses the client's vital signs and asks about symptoms
- C. The nurse determines that the client is not meeting his set outcomes and makes revisions
- D. The nurse discusses the client's health history
Correct Answer: C
Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.