Nokea
How can the nurse help monitor effectiveness of therapy for the patient with a pneumothorax and chest-drainage system?
- A. Palpate for crepitus
- B. Document color and amount of sputum
- C. Auscultate lung sounds
- D. Monitor suction level
Correct Answer: C
Rationale: The correct answer is C: Auscultate lung sounds. By auscultating lung sounds, the nurse can assess for changes in breath sounds which can indicate improvement or deterioration in the patient's condition. This helps monitor the effectiveness of therapy for a pneumothorax and chest-drainage system. Palpating for crepitus (A) is not directly related to monitoring therapy effectiveness. Documenting sputum color and amount (B) is important but does not specifically monitor therapy effectiveness. Monitoring suction level (D) is crucial but does not directly assess the patient's response to therapy.
You may also like to solve these questions
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care.
Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.
The most significant form of meningitis is:
- A. Bacterial
- B. Septic
- C. Aseptic
- D. Viral
Correct Answer: A
Rationale: The correct answer is A: Bacterial meningitis. Bacterial meningitis is the most significant form due to its potential severity and rapid progression, requiring urgent medical intervention with antibiotics. Bacterial meningitis can lead to serious complications such as brain damage or death if left untreated. Septic meningitis (choice B) refers to meningitis caused by a systemic infection spreading to the meninges. Aseptic meningitis (choice C) is typically viral or non-bacterial in origin, usually milder than bacterial meningitis. Viral meningitis (choice D) is less severe than bacterial meningitis and often resolves on its own without specific treatment.
A patient is diagnosed with Hashimoto’s thyroiditis and asks what causes it. The nurse would respond that the destruction of the thyroid in this condition is due to which of the following?
- A. Antigen-antibody complexes
- B. Viral infection
- C. Autoantibodies
- D. Bacterial infection
Correct Answer: C
Rationale: The correct answer is C: Autoantibodies. In Hashimoto's thyroiditis, the immune system mistakenly attacks the thyroid gland by producing autoantibodies against thyroid proteins such as thyroglobulin and thyroid peroxidase. These autoantibodies lead to inflammation and destruction of thyroid tissue. Antigen-antibody complexes (choice A) are not the main mechanism in Hashimoto's thyroiditis. Viral (choice B) and bacterial infections (choice D) do not directly cause autoimmune destruction of the thyroid in this condition. Autoantibodies targeting the thyroid gland are the key pathogenic factor in Hashimoto's thyroiditis.
When caring for an anxious patient with dyspnea, which of the ff. nursing actions is most helpful to include in the plan of care to relieve anxiety?
- A. Increasing activity levels
- B. Pulling the privacy curtain
- C. Staying at patient’s bedside
- D. Closing the patient’s door
Correct Answer: C
Rationale: The correct answer is C: Staying at patient's bedside. This is the most helpful nursing action because it provides reassurance and support to the anxious patient experiencing dyspnea. By staying at the bedside, the nurse can monitor the patient closely, provide immediate assistance if needed, and offer a calming presence.
Explanation of why other choices are incorrect:
A: Increasing activity levels may worsen the dyspnea and anxiety of the patient.
B: Pulling the privacy curtain does not directly address the patient's anxiety or dyspnea.
D: Closing the patient's door may make the patient feel isolated and increase anxiety.
In summary, staying at the patient's bedside is the most effective nursing action as it addresses both the physical and emotional needs of the anxious patient with dyspnea.
What is the focus of a diagnostic statement for a collaborative problem?
- A. The client problem
- B. The potential complication
- C. The nursing diagnosis
- D. The medical diagnosis
Correct Answer: B
Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying any potential complications that may arise due to the client's condition or treatment. This allows nurses and other healthcare professionals to anticipate and address these complications proactively.
A: The client problem - While important, the client problem is usually addressed in the nursing diagnosis rather than the diagnostic statement for a collaborative problem.
C: The nursing diagnosis - The nursing diagnosis focuses on the actual or potential health problems that the client is experiencing, which is different from the focus of a diagnostic statement for a collaborative problem.
D: The medical diagnosis - The medical diagnosis is the identification of a disease or condition by a healthcare provider, which is not the focus when identifying potential complications in a collaborative problem.