An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
- A. Potential for infection
- B. Self care deficit
- C. Alteration in infection
- D. Fluid volume excess
Correct Answer: A
Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results 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.
Which of the following is the appropriate nursing diagnosis?
- A. Fluid volume deficit R/T furrow tongue
- B. Fluid volume deficit R/T uncontrolled vomiting
- C. Dehydration R/T subnormal body temperature
- D. Dehydration R/T incessant vomiting
Correct Answer: B
Rationale: The correct answer is B, "Fluid volume deficit R/T uncontrolled vomiting." This option correctly identifies the cause of the fluid volume deficit as uncontrolled vomiting, which is a common reason for fluid loss. The nursing diagnosis should always reflect the underlying cause of the issue.
A is incorrect as "furrow tongue" is not a recognized medical term related to fluid volume deficit.
C is incorrect because dehydration is not typically related to subnormal body temperature unless it is severe.
D is incorrect as incessant vomiting is more specific to the cause, but the term "dehydration" should be used instead of "fluid volume deficit" in this context.
In summary, option B is the appropriate nursing diagnosis as it accurately links the fluid volume deficit to the cause of uncontrolled vomiting.
Mr. RR is to have a brain scanning. Nursing intervention in preparation for this test includes:
- A. Discontinuing any anticonvulsant therapy
- B. Obtaining consent for the treatment
- C. Explaining to Mr. RR that although his head will be supported in place for a period of time, the test will not be painful.
- D. Informing Mr. RR that nausea and headache are frequent following this test
Correct Answer: C
Rationale: The correct answer is C because it addresses the specific nursing intervention needed to prepare Mr. RR for the brain scanning test. By explaining to Mr. RR that the test will not be painful and that his head will be supported in place, the nurse helps alleviate any potential anxiety or fear he may have. This information reassures the patient and ensures his cooperation during the procedure.
Choice A is incorrect because discontinuing anticonvulsant therapy without medical approval could have serious consequences for Mr. RR's health. Choice B is also incorrect as obtaining consent is important, but it is not directly related to preparing Mr. RR for the test. Choice D is incorrect as it introduces potential negative outcomes without providing necessary information to prepare the patient for the test.
A client comes to her health care provider’s office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?
- A. Initial assessment
- B. Focused assessment
- C. Emergency assessment
- D. Time-lapsed assessment
Correct Answer: B
Rationale: The correct answer is B: Focused assessment. In this scenario, the client's abdominal pain is a known issue, so a focused assessment would be appropriate to gather specific information related to the current complaint. A focused assessment allows the nurse to concentrate on the particular problem at hand, which in this case is the abdominal pain.
A: Initial assessment is not applicable as the client has been seen for this issue before.
C: Emergency assessment is not necessary as the situation does not indicate an urgent or life-threatening condition.
D: Time-lapsed assessment is not suitable because it involves assessing changes over time, which is not the primary concern in this scenario.
In summary, a focused assessment is the most appropriate choice as it allows the nurse to address the client's specific complaint efficiently.
During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
- A. An increase in the client’s blood pressure
- B. An increase in the client’s respiratory rate
- C. An increase in the client’s heart rate
- D. A decrease in blood loss
Correct Answer: A
Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A.
Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.