Nokea
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
- A. To form a language that can be encoded only by nurses
- B. To distinguish the nurse’s role from the physician’s role
- C. To develop clinical judgment based on other’s intuition
- D. To help nurses focus on the scope of medical practice
Correct Answer: D
Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery.
A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs.
B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role.
C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.
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During a breast examination, which finding most strongly suggests that the client has breast cancer?
- A. Slight asymmetry of the breasts
- B. A fixed nodular mass with dimpling of the overlying skin
- C. Bloody discharge from the nipple
- D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.
Which finding will alert the nurse that the goal has been met?
- A. Heart rate 78 beats/min on 12/3
- B. Heart rate 78 beats/min on 12/4
- C. Heart rate 80 beats/min on 12/3
- D. Heart rate 80 beats/min on 12/4
Correct Answer: A
Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.
Which of the following hormones retains sodium in the body?
- A. Antidiuretic hormone
- B. Aldosterone
- C. Thyroid hormone
- D. Insulin
Correct Answer: B
Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance.
A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention.
C: Thyroid hormone does not directly influence sodium retention.
D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.
A patient has iron deficiency anemia. Which of the following foods will best help provide dietary iron?
- A. Fresh fruits
- B. Dairy products
- C. Lean red meats
- D. Breads and cereals
Correct Answer: C
Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
- A. status of client’s tetanus immunization
- B. current blood alcohol level
- C. support systems available at home to assist with care
- D. last time client voided
Correct Answer: A
Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications.
Incorrect choices:
B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture.
C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority.
D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.