Nokea
In teaching a female client who is HIV positive about pregnancy, the nurse would know more teaching is necessary when the client says:
- A. “The baby can get the virus from my placenta.”
- B. “I’m planning on starting on birth control pills.”
- C. “Not everyone who has the virus gives birth to a baby who has the virus.”
- D. “I’ll need to have a C-section if I become pregnant and have a baby.”
Correct Answer: B
Rationale: The correct answer is B because starting birth control pills does not protect against HIV transmission to the baby during pregnancy. The other choices demonstrate understanding of HIV transmission risks and prevention methods. A shows awareness of vertical transmission, C recognizes that not all babies born to HIV-positive mothers are infected, and D acknowledges the potential need for a C-section to reduce transmission risk. Starting birth control pills is unrelated to preventing mother-to-child HIV transmission during pregnancy.
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A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: 'Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?
- A. Disturbed thought processes
- B. Related to
- C. Alzheimer’s disease
- D. Incoherent language
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This is the problem statement because it identifies the specific nursing diagnosis that reflects the client's cognitive impairment. "Disturbed thought processes" directly addresses the issue the nurse is observing in the client. The other choices are not the problem statement. "Related to" is the etiology or cause of the problem, "Alzheimer’s disease" is the medical condition, and "Incoherent language" is the defining characteristic or evidence of the problem. Therefore, A is the correct answer as it clearly states the client's primary issue.
In which of the ff circumstances should a nurse avoid using midline and mid clavicular sites for IV therapy? Choose all that apply.
- A. To administer solutions with a pH greater than 5 and less than 9
- B. To administer antineoplastic chemotherapy
- C. To administer slow, low-volume infusions
- D. To administer high-pressure bolus injections
Correct Answer: B
Rationale: The correct answer is B: To administer antineoplastic chemotherapy. This is because antineoplastic chemotherapy agents are highly irritating and toxic to the surrounding tissues. Using midline and mid clavicular sites for IV therapy in this case can increase the risk of extravasation, leading to tissue damage and potential complications.
Incorrect choices:
A: To administer solutions with a pH greater than 5 and less than 9 - pH of the solution does not directly affect the choice of site for IV therapy.
C: To administer slow, low-volume infusions - Midline and mid clavicular sites can be appropriate for slow, low-volume infusions.
D: To administer high-pressure bolus injections - While midline and mid clavicular sites may not be ideal for high-pressure bolus injections, the question specifically mentions IV therapy, not bolus injections.
Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.
Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: The correct answer is C because washing feet in hot water can lead to burns or skin damage for those with diabetes. A: Proper footwear is essential for preventing foot injuries. B: Trimming toenails straight across helps prevent ingrown nails. D: Wearing shoes on hot surfaces prevents burns or blisters. Overall, C is incorrect due to the potential harm it can cause to diabetic feet.
Nutritional considerations as part of the nursing care plan would include all of the following except that:
- A. The diet should be semisolid to facilitate the passage of food
- B. Calcium should be avoided
- C. The patient should be sitting in an upright position during feeding
- D. Thick fluids should be encouraged to provide additional calories NEUROLOGIC Situation - Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.
Correct Answer: B
Rationale: Correct Answer: B: Calcium should be avoided
Rationale:
1. Calcium is an essential mineral for bone health, especially important for individuals with limited mobility like Richard.
2. Avoiding calcium can lead to bone weakening and increase the risk of fractures.
3. Nursing care plans should include adequate calcium intake to support bone health.
4. Therefore, avoiding calcium is not a recommended nutritional consideration.
Summary of Incorrect Choices:
A: The diet should be semisolid to facilitate the passage of food - This is important for individuals with swallowing difficulties.
C: The patient should be sitting in an upright position during feeding - This aids in proper digestion and reduces the risk of aspiration.
D: Thick fluids should be encouraged to provide additional calories - Thick fluids may increase the risk of aspiration in patients with neurological conditions.