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According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Impaired urinary elimination
- D. Risk for body image disturbance
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.
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A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for their health care. By focusing on the patient's expectations, the nurse can establish a therapeutic relationship, provide patient-centered care, and tailor the care plan accordingly.
A: Nurse's concerns - Incorrect. The nursing health history should prioritize the patient's perspective and needs over the nurse's concerns.
C: Current treatment orders - Incorrect. While important, this component focuses on the medical treatment plan rather than the patient's expectations.
D: Nurse's goals for the patient - Incorrect. The nurse should collaborate with the patient to set goals that align with the patient's needs and preferences, not impose their own goals.
A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is to:
- A. Prevent infection postoperatively
- B. Eliminate the need for preoperative enemas
- C. Decreased and retard the growth of normal bacteria in the intestines
- D. Treat cancer of the colon
Correct Answer: C
Rationale: The correct answer is C because Neomycin is given preoperatively to decrease and retard the growth of normal bacteria in the intestines. This helps reduce the risk of infection during surgery by minimizing the number of bacteria present in the colon. Options A, B, and D are incorrect because Neomycin is not given to prevent infection postoperatively, eliminate the need for preoperative enemas, or treat cancer of the colon. The main purpose of administering Neomycin in this scenario is to create a sterile surgical field by reducing the normal flora in the intestines.
When caring for a client with diabetes insipidus, the nurse expects to administer:
- A. Vasopressin (Pitressin Synthetic)
- B. Regular insulin
- C. Furosemide (Lasix)
- D. 10% dextrose
Correct Answer: A
Rationale: The correct answer is A: Vasopressin (Pitressin Synthetic). In diabetes insipidus, there is a deficiency of ADH (antidiuretic hormone), leading to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps retain water by reducing urine output. Administering vasopressin helps manage the symptoms of diabetes insipidus.
B: Regular insulin is used to manage diabetes mellitus, not diabetes insipidus.
C: Furosemide is a diuretic used to increase urine output, which would worsen the symptoms of diabetes insipidus.
D: 10% dextrose is a form of glucose and is not indicated in the treatment of diabetes insipidus.
Mr. Reyes has a possible skull fracture. The nurse should:
- A. Observe him for signs of Brain injury
- B. Check for hemorrhaging from the oral cavity
- C. Elevate the foot of the bed if he develops symptoms of shock
- D. Observe for symptoms of decreased intracranial pressure and temperature
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
- A. Decreased gastrointestinal motility
- B. Pain medication
- C. Abdominal distention
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.