Nokea
For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.
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A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
- A. Poor impulse control
- B. Inability to discriminate words and letters
- C. Deficits in the right visual field
- D. Motor retardation
Correct Answer: A
Rationale: The correct answer is A: Poor impulse control. When a client has a stroke involving the right cerebral hemisphere, it can affect their ability to regulate emotions and impulses. The right hemisphere is responsible for inhibiting impulsive behavior, so damage to this area can lead to poor impulse control. This can manifest as impulsivity, lack of judgement, and difficulty controlling emotions.
Summary of Incorrect Choices:
B: Inability to discriminate words and letters - This is typically associated with left cerebral hemisphere damage, not right hemisphere.
C: Deficits in the right visual field - This is associated with damage to the left occipital lobe, not the right hemisphere.
D: Motor retardation - Motor functions are controlled by the opposite side of the brain, so right hemisphere damage would typically affect the left side of the body, not motor function in general.
How should the nurse position Mr. Jones’ chest drainage unit while he is transported?
- A. Below the chest level
- B. On the stretcher
- C. The unit should be removed
- D. The tubes should be clamped
Correct Answer: A
Rationale: The correct answer is A: Below the chest level. Positioning the chest drainage unit below the chest level allows for effective drainage of air or fluid from the chest cavity. Placing it above the chest level may cause backflow or air/fluid accumulation. Option B is incorrect as the unit should be secured to prevent dislodging during transport. Option C is incorrect as removing the unit can lead to complications. Option D is incorrect as clamping the tubes can result in a tension pneumothorax. Positioning the unit below the chest level ensures proper drainage and prevents complications during transport.
Mary asks how the pulmonary function test ordered by her physician is performed. You respond by saying
- A. You breathe into a spirometer to measure your lung capacity.
- B. You breathe through a mouthpiece into a spirometer until all air in your lungs is expelled; then you take a deep breath through the mouthpiece. This is done three times and a computer calculates the capacity of your lungs.
- C. A computer is used to measure your volume and vital capacity.
- D. A tube is inserted into your lungs while you are asleep to expand your lungs to their full capacity.
Correct Answer: B
Rationale: Pulmonary function tests measure lung capacity using spirometry.
The nurse identifies the presence of age-associated memory impairment in the older adult who states
- A. I just can't seem to remember the name of my granddaughter.
- B. I make out lists to help me remember what I need to do but I can't seem to use them.
- C. I forgot that I went to the grocery store this morning and didn't realize it until I went again this afternoon.
- D. I forget movie stars' names more often now but I can remember them later after the conversation is off.
Correct Answer: C
Rationale: Age-associated memory impairment typically involves short-term memory lapses rather than complete forgetting. Forgetting actions like visiting the grocery store earlier in the day aligns with this type of impairment.
What are these sensory phenomena called when a client hears voices or sees images that do not objectively exist?
- A. Mania
- B. Delusions
- C. Seasonal affective disorder
- D. Hallucinations
Correct Answer: D
Rationale: Hallucinations involve perceiving things that are not present, such as hearing voices or seeing images.