Nokea
In monitoring patients who are at risk for spinal cord compression related to tumor growth, what is the most likely early manifestation?
- A. Sudden-onset back pain.
- B. Motor loss.
- C. Constipation.
- D. Urinary hesitancy.
Correct Answer: A
Rationale: Sudden-onset back pain is often the first symptom of spinal cord compression and warrants urgent evaluation.
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A hospitalized Native American patient tells the nurse that later in the day a medicine man from his tribe is coming to perform a healing ceremony to return his world to balance. What should the nurse recognize about this situation?
- A. The patient does not adhere to an organized,formal religion.
- B. The patient’s spiritual needs may be met by traditional rituals.
- C. The patient’s spiritual needs may be met by traditional rituals.
- D. The patient may be putting his health in jeopardy by relying on rituals.
Correct Answer: B
Rationale: Traditional rituals such as those performed by a medicine man can meet the spiritual needs of Native American patients. This approach respects their cultural beliefs without undermining conventional medical treatment.
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.
What is the first sign that the condition of a dying client is worsening?
- A. Pulmonary function impairment
- B. Peripheral circulation changes
- C. Central nervous system alterations
- D. Failing cardiac function
Correct Answer: C
Rationale: Central nervous system changes, such as confusion or lethargy, often indicate declining health in terminal stages.
A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
- A. Diarrhea/Constipation related to altered bowel patterns.
- B. Knowledge Deficit related to disease process and diagnostic procedure.
- C. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea.
- D. Anxiety related to unknown outcomes and perceived threats to body integrity.
Correct Answer: D
Rationale: The patient's anger and threat to leave indicate significant anxiety, which must be addressed before proceeding with education or further assessment.
A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?
- A. Use incentive spirometer every 4 hours while awake.
- B. Initiate ambulation after discontinuing the NG tube.
- C. Maintain a supine position with an abdominal binder.
- D. Splint the incision to support coughing every 2 hours.
Correct Answer: D
Rationale: The correct answer is D because splinting the incision supports coughing, which helps clear secretions and prevents respiratory complications. It is essential postoperatively to prevent atelectasis and pneumonia. Using an incentive spirometer (A) aids in lung expansion but does not directly support coughing. Ambulation (B) promotes circulation but does not address respiratory concerns. Maintaining a supine position with an abdominal binder (C) may restrict diaphragmatic movement and increase the risk of respiratory complications.