Nokea
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
- A. Have her rate her pain on a 0 to 10 scale
- B. Administer antibiotics as ordered
- C. Administer an analgesic as ordered
- D. Teach the patient about causes and prevention of STDs
Correct Answer: B
Rationale: The correct action is to administer antibiotics as ordered first because pelvic inflammatory disease is caused by an infection, usually from sexually transmitted organisms. Administering antibiotics promptly is crucial to prevent further complications and treat the underlying infection. This helps to alleviate the source of the pain. Rating pain severity, administering analgesics, and patient education are important but should come after addressing the infection to prevent worsening of the condition.
You may also like to solve these questions
The clinical manifestations of Parkinson’s disease (bradykinesia rigidity and tremors) is directly related to a decreased level of:
- A. Acetylcholine
- B. Serotonin
- C. Dopamine
- D. Phenylalanine
Correct Answer: C
Rationale: The correct answer is C: Dopamine. Parkinson's disease is primarily caused by a deficiency of dopamine in the brain, leading to the characteristic symptoms of bradykinesia, rigidity, and tremors. Dopamine is a neurotransmitter involved in movement control. Acetylcholine (Choice A) is not directly related to Parkinson's disease, although its imbalance can contribute to other movement disorders. Serotonin (Choice B) and Phenylalanine (Choice D) are not primarily involved in the pathophysiology of Parkinson's disease.
Nurse Nancy also gives a lecture at the community health center about the diet for patients with ulcerative colitis. Which one is appropriate?
- A. high calorie, low protein
- B. low fat, high fiber
- C. high protein, low residue
- D. low sodium, high carbohydrate
Correct Answer: C
Rationale: The correct answer is C: high protein, low residue. For patients with ulcerative colitis, a high protein diet helps in tissue healing and repair. Low residue foods are recommended to reduce bowel irritation. Choice A is incorrect because low protein can impair healing. Choice B is unsuitable as high fiber may worsen symptoms. Choice D is not ideal as high carbohydrate can be difficult to digest for colitis patients.
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
- A. Hypoalbuminemia with hemoconcentration
- B. Volume overload with hemodilution
- C. Metabolic acidosis
- D. Lack of erythropoeitin factor
Correct Answer: B
Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.
Which of the ff should the nurse include in the teaching plan of a client with acute bronchitis?
- A. Not coughing frequently
- B. Washing the hands frequently
- C. Consuming adequate calories
- D. Encouraging a semi-Fowler’s position
Correct Answer: B
Rationale: The correct answer is B: Washing the hands frequently. This is important for preventing the spread of infection, which is crucial in acute bronchitis. By washing hands frequently, the client can reduce the risk of transmitting the infection to others and prevent reinfection.
A: Not coughing frequently - While managing cough is important, it is not the most crucial aspect in the teaching plan for acute bronchitis.
C: Consuming adequate calories - While nutrition is important for overall health, it is not specifically related to the management of acute bronchitis.
D: Encouraging a semi-Fowler’s position - While this position can help with breathing, it is not the most important aspect in the teaching plan for acute bronchitis.