Nokea
Appropriate nursing interventions for J.E. would be
- A. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
- B. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive pressure breathing therapy
- C. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and intermittent positive pressure breathing q2h
- D. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief devices Situation - Mr. Reyes suffered head injuries in a motor vehicle accident
Correct Answer: A
Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.
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A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?
- A. Keep all side rails down at all times.
- B. Encourage patient to remain in bed most of the shift.
- C. Place patient in room away from the nurses’ station if possible.
- D. Assist patient into and out of bed every 4 hours or as tolerated.
Correct Answer: D
Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support.
A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls.
B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls.
C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies.
In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.
After a 3- month trail of dietary therapy, a client with type2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:
- A. 30 minutes before breakfast
- B. 30 minutes after dinner.
- C. in the midmorning
- D. at bedtime.
Correct Answer: A
Rationale: The correct answer is A: 30 minutes before breakfast. Glyburide is a sulfonylurea medication that stimulates insulin release from the pancreas, enhancing glucose uptake. Taking it before breakfast ensures peak insulin levels coincide with the postprandial glucose spike, aiding in glucose control throughout the day. Option B is incorrect as taking it after dinner may lead to hypoglycemia during sleep. Option C is incorrect as midmorning is not an optimal time for a sulfonylurea dose. Option D is incorrect as taking it at bedtime may also increase the risk of hypoglycemia overnight.
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature
- B. Allow him to wear his own clothing
- C. Encourage to perform his own personal
- D. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.
A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?
- A. Bacterial infection
- B. High-fat diet
- C. Heredity
- D. Autoimmune reaction
Correct Answer: D
Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
- A. Naturally acquired passive immunity
- B. Naturally acquired active immunity
- C. Artificially acquired passive immunity
- D. Artificially acquired active immunity
Correct Answer: A
Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.