Nokea
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process f. A reflection of coping mechanisms used to deal with the exacerbation of her illness g. Indicative of the remission phase of her chronic illness h. Realistic for her current level of physical functioning
Correct Answer: B
Rationale: Step 1: The scenario describes Toni minimizing her visual problems, planning advanced degrees, seeking full-time jobs, and wanting more children.
Step 2: Choice B is correct because it recognizes Toni's behavior as a coping mechanism to deal with her illness.
Step 3: Minimizing visual problems and focusing on future goals can be a way for Toni to maintain a positive outlook and cope with her challenges.
Step 4: Choices A, C, and D are incorrect because they do not address Toni's behavior as a coping mechanism. Choice A mentions euphoria, which is not supported by the scenario. Choice C and D do not acknowledge Toni's coping mechanism but instead focus on different aspects like disease process and physical functioning.
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Which of the ff would describe the discomfort experienced by a client with a tension headache?
- A. A heavy feeling over the frontal region and sensitivity to light
- B. Pressure or steady constriction on both sides of the head
- C. Headache and temporary unilateral paralysis
- D. Vague headache, especially peri orbital
Correct Answer: B
Rationale: The correct answer is B because tension headaches typically present as a feeling of pressure or steady constriction on both sides of the head. This is due to muscle tension in the head and neck. Choice A is incorrect as sensitivity to light is more characteristic of migraines. Choice C is incorrect as unilateral paralysis is not typically associated with tension headaches. Choice D is incorrect as vague headache especially peri orbital is not a common symptom of tension headaches. Therefore, the best description of discomfort experienced by a client with a tension headache is the pressure or steady constriction on both sides of the head.
Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
- A. Fruity odor of the breath
- B. shallow, deep respirations
- C. severe dehydration
- D. profuse sweating
Correct Answer: C
Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
- A. Determines whether an intervention is correct and appropriate for the given situation
- B. Reads over the steps and performs a procedure despite lack of clinical competency
- C. Establishes goals for a particular patient without assessment
- D. Evaluates the effectiveness of interventions
Correct Answer: A
Rationale: The correct answer is A because determining whether an intervention is correct and appropriate for the given situation indicates critical thinking in nursing care implementation. This involves assessing the patient's needs, analyzing the situation, and using evidence-based practice to make informed decisions. This process ensures that interventions are tailored to individual patient needs and promotes safe and effective care delivery.
Option B is incorrect because performing a procedure without clinical competency can jeopardize patient safety and is not an example of critical thinking. Option C is incorrect as establishing goals without assessment lacks a foundation in data and may lead to inappropriate care planning. Option D is incorrect as evaluating the effectiveness of interventions is a part of the nursing process but does not specifically demonstrate critical thinking in implementation.
What is the primary purpose of the outcome identification and planning step of the nursing process?
- A. To collect and analyze data to establish a database
- B. To interpret and analyze data so as to identify health problems
- C. To write appropriate client-centered nursing diagnoses
- D. To design a plan of care for and with the client
Correct Answer: D
Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.
When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
- A. Wear gloves at all times
- B. Wear gown and mask at all times
- C. Wear gloves for blood/body fluid contact
- D. Wear a mask during patient contact times
Correct Answer: C
Rationale: The correct answer is C: Wear gloves for blood/body fluid contact. This is the most appropriate action for infection control when caring for a patient with AIDS because HIV is primarily transmitted through blood and certain body fluids. Wearing gloves when coming into contact with blood or body fluids reduces the risk of transmission.
Explanation for why other choices are incorrect:
A: Wearing gloves at all times may not be necessary and can lead to unnecessary waste of resources.
B: Wearing gown and mask at all times is excessive and not indicated unless there is a risk of exposure to blood or body fluids.
D: Wearing a mask during patient contact times is not necessary unless there is a risk of exposure to respiratory secretions.