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As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Anaphylaxis is a severe allergic reaction that can lead to airway constriction and difficulty breathing, resulting in wheezing. Wheezing is a common symptom of anaphylaxis due to bronchospasm and airway swelling. Dermatitis (A) is a skin reaction, sinusitis (B) is inflammation of the sinuses, and delirium (C) is a state of mental confusion, which are not typical symptoms of anaphylaxis. Wheezing is a critical symptom in anaphylaxis as it indicates potential airway compromise and the need for immediate medical intervention.
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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.
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.
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, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because:
A: Nurse's concerns are not the primary focus of a nursing health history.
C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care.
D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
- A. “Take ferrous sulfate and the antacid together.”
- B. “Take ferrous sulfate and the antacid at least 2 hours apart.”
- C. “Avoid taking an antacid altogether.”
- D. “Take ferrous sulfate and the antacid at least 1 hour apart.”
Correct Answer: B
Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart."
Rationale:
1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity.
2. Antacids can bind to iron and reduce its absorption.
3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid.
4. Taking them together (choice A) would decrease iron absorption.
5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately.
6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.
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.