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Mr. RR is being prepared for surgery. Nursing care would include:
- A. Careful assessment of neurologic signs to establish baseline data for post-operative care
- B. Planning activities for Mr. RR
- C. Administration of an SS enema to prevent post-operative impaction
- D. Explaining to Mr. RR post-operative complications
Correct Answer: A
Rationale: Nursing care for a patient being prepared for surgery includes conducting a careful assessment of neurologic signs to establish baseline data for post-operative care. Assessing the patient's neurologic status preoperatively is important for early detection of any post-operative complications such as changes in consciousness, sensation, or movement. This baseline data will be used to monitor and evaluate the patient's recovery and response to the surgery, anesthesia, and post-operative care interventions. Planning activities, administering enemas, and explaining post-operative complications are also important aspects of nursing care but assessing neurologic signs is the priority in this scenario.
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Which action by the school nurse is important in the prevention of rheumatic fever?
- A. Encourage routine cholesterol screenings.
- B. Conduct routine blood pressure screenings.
- C. Refer children with sore throats for throat cultures.
- D. Recommend salicylates instead of acetaminophen for minor discomforts.
Correct Answer: C
Rationale: Referring children with sore throats for throat cultures is important in the prevention of rheumatic fever. Rheumatic fever is a complication of untreated streptococcal throat infections, specifically caused by group A Streptococcus bacteria. By identifying and treating streptococcal infections promptly with antibiotics, the risk of developing rheumatic fever is significantly reduced. The school nurse plays a crucial role in recognizing the symptoms of strep throat and ensuring that affected children are appropriately referred for testing and treatment. This can help prevent the serious consequences of rheumatic fever, which can affect the heart, joints, skin, and brain if left untreated. Encouraging routine cholesterol screenings (choice A) and blood pressure screenings (choice B) are important for overall health monitoring but are not directly related to the prevention of rheumatic fever. Recommending salicylates over acetaminophen (choice D) is not advisable in children due to the risk of Reye's syndrome
The nurse is developing a teaching plan for a patient. Which of the following is a modifiable risk factor for the development of hypertension? i.Race iv.Sedentary lifestyle ii.High cholesterol v.Age iii.Cigarette smoking
- A. 1 and 2
- B. 2, 3, 4 and 5
- C. 2, 3 and 4
- D. All of the above
Correct Answer: C
Rationale: High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for the development of hypertension. Race and age are non-modifiable risk factors. By targeting high cholesterol, cigarette smoking, and promoting physical activity, the nurse can help the patient reduce their risk of developing hypertension. It is important to focus on these modifiable factors in the teaching plan to empower the patient to make positive lifestyle changes and improve their overall health.
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: A
Rationale: Cystoclisis refers to the continuous irrigation of the bladder with a sterile solution to maintain bladder atony. This procedure is commonly done to provide continuous bladder drainage, prevent clot formation, and promote urinary flow. By continuously irrigating the bladder, it helps to keep the bladder decompressed and prevent the overdistension of the bladder muscles, especially in patients with impaired bladder emptying or bladder dysfunction. Therefore, the purpose of cystoclisis is to increase bladder atony rather than the other options listed.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends's behavior shows that they aren't true friends
Correct Answer: C
Rationale: It is important for the nurse to listen and show interest as the client expresses their feelings in this situation. The client's emotional distress is a valid response to feeling abandoned by friends and family during a difficult time. By providing a supportive and empathetic presence, the nurse can help the client feel valued and understood, promoting emotional well-being and potentially increasing the client's sense of comfort and trust in the healthcare setting. This approach validates the client's feelings and fosters therapeutic communication, which is crucial in providing holistic care to individuals with complex health needs such as AIDS and Pneumocystis carinii pneumonia. It is essential to acknowledge and address the client's emotional needs in addition to their physical care.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: A diagnosis of breast cancer is confirmed through a biopsy, which involves removing a sample of tissue or cells from the lump in the breast and examining it under a microscope. Fine needle aspiration is a minimally invasive procedure where a thin needle is used to remove cells from the lump for examination. This diagnostic method allows for the confirmation of breast cancer by analyzing the cells for signs of malignancy. While breast self-examinations, mammography, and chest x-rays are important tools for detecting breast abnormalities, they are not definitive in confirming a diagnosis of breast cancer.