Nokea
For this patient who is to undergo surgery (closure of the sac), what would be the PRIORITY nursing diagnosis? It is risk for __________.
- A. Activity intolerance
- B. Infection
- C. Respiration
- D. Altered growth and development
Correct Answer: B
Rationale: The priority nursing diagnosis for a patient undergoing surgery (closure of the sac) would be risk for infection. This is because surgical procedures increase the risk of infection due to the breach in the skin and introduction of microorganisms. Infection can lead to serious complications, delay healing, and prolong recovery time. Therefore, prevention, early detection, and prompt treatment of infections are essential in the perioperative period to ensure the best possible outcomes for the patient.
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Which of the following is the cause of Somogyi effect, which occurs during sleep in patients with diabetes mellitus?
- A. too much globulin
- B. too much albumin
- C. increase insulin in the body
- D. limited insulin in the body
Correct Answer: D
Rationale: The Somogyi effect, also known as rebound hyperglycemia, is a phenomenon observed in patients with diabetes mellitus during sleep. It is characterized by a low blood sugar level (hypoglycemia) followed by high blood sugar (hyperglycemia) in the morning. This occurs due to limited insulin in the body during the night, leading to high blood sugar levels in the morning as a response to the hypoglycemia episode. Too much globulin or albumin are not directly associated with the Somogyi effect. Increasing insulin in the body would rather help prevent the hypoglycemia episode that triggers the rebound hyperglycemia in the Somogyi effect.
Cell-mediated immunity is NOT usually associated with what condition:
- A. Rejection of tissue graft
- B. Production of antibodies
- C. Skin hypersensitivity reaction
- D. Surveying for malignant cells
Correct Answer: B
Rationale: Cell-mediated immunity is a type of immune response that involves the activation of cytotoxic T cells and other immune cells to directly target and destroy infected or abnormal cells. It does not involve the production of antibodies, which are the primary component of humoral immunity. Antibodies are produced by B cells and are responsible for targeting extracellular pathogens such as bacteria and viruses. In contrast, cell-mediated immunity is more focused on targeting intracellular pathogens, cancerous cells, and other cells that have been compromised. So, production of antibodies is not usually associated with cell-mediated immunity.
Which BEST describes the planning function of Nurse Ellen in her role as nurse manager?
- A. Get and develop people to do work
- B. Distributes and arranges work to ensure smooth operation of the unit.
- C. Determines the actual performance compared with the desired output.
- D. Determine how to achieve the mandate of work.
Correct Answer: D
Rationale: The planning function of Nurse Ellen in her role as a nurse manager best corresponds to option D, which is to determine how to achieve the mandate of work. Planning involves setting objectives, developing strategies, and outlining the steps to accomplish those objectives. As a nurse manager, Nurse Ellen would be responsible for creating plans to ensure the effective delivery of patient care, efficient allocation of resources, and meeting the organizational goals of the unit. By determining how to achieve the work mandate, Nurse Ellen can effectively lead her team, allocate resources efficiently, and navigate any challenges that may arise in the operation of the nursing unit.
How should the nurse position the patient who is in a somnolent status and still under the effect of anesthesia?
- A. Supine position with head bed slightly elevate.
- B. Prone position with a pillow under the abdomen.
- C. Semi-Fowler's position with the head turned to the right.
- D. Left lateral position with a pillow supporting the head.
Correct Answer: A
Rationale: When a patient is in a somnolent status and still under the effect of anesthesia, the most appropriate position to place the patient is in a supine position with the head of the bed slightly elevated. This position helps prevent any obstruction of the airway and promotes optimal ventilation. Elevating the head of the bed ensures that the patient's airway remains clear and allows for proper breathing. Additionally, this position helps prevent aspiration and promotes proper circulation. Overall, the supine position with the head bed slightly elevated is the safest and most effective position for a patient in this condition.
The BEST example of how the nurse can create a climate in which clients do not feel threatened is by teaching on a topic about:
- A. Stress, where the nurse plays pop music throughout the first session
- B. Good nutrition, while the nurse provides a meal
- C. Exercise, where the nurse begins to share her difficulties she sometimes finds in trying to exercise
- D. Diabetes, where the nurse asks diabetics to talk to the class during the first session
Correct Answer: B
Rationale: The best example of how the nurse can create a climate in which clients do not feel threatened is by teaching on good nutrition while providing a meal. This approach not only addresses an important topic that is beneficial for the clients but also creates a comfortable and welcoming atmosphere. By offering a meal, the nurse is able to engage the clients in a familiar and non-threatening activity, making them more receptive to the information being shared. Additionally, sharing a meal can help to build rapport and create a sense of community among the clients and the nurse, leading to a more positive learning experience.