Nokea
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to chronic leg pain)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct Answer: D
Rationale: The most appropriate nursing diagnosis for Mrs. Peterson is 'Sleep Pattern Disturbances (related to chronic leg pain).' Mrs. Peterson's sleep issues are directly linked to her chronic leg pain, which is a result of her arthritis. This nursing diagnosis addresses the primary cause of her sleep disturbances and allows for interventions that focus on managing the pain to improve her sleep. Choices A, B, and C are incorrect. Choice A correctly identifies the relationship between sleep disturbances and chronic leg pain, addressing the root cause. Choice B is incorrect as it only focuses on fatigue and does not encompass the broader sleep issues. Choice C is not relevant as there is no indication that Mrs. Peterson lacks knowledge about sleep hygiene measures.
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Which of the following lab values is associated with a decreased risk of cardiovascular disease?
- A. high HDL cholesterol
- B. low HDL cholesterol
- C. low total cholesterol
- D. low triglycerides
Correct Answer: B
Rationale: High HDL cholesterol is associated with a decreased risk of cardiovascular disease because HDL cholesterol is known as 'good' cholesterol. It helps remove other forms of cholesterol, like LDL cholesterol, from the bloodstream, reducing the risk of plaque buildup in the arteries. Low HDL cholesterol (Choice B) is actually a risk factor for cardiovascular disease because it means there is less of the 'good' cholesterol to perform its protective functions. Low total cholesterol (Choice C) and low triglycerides (Choice D) are not necessarily associated with a decreased risk of cardiovascular disease, as the balance and types of cholesterol play a more crucial role in heart health.
Major competencies for the nurse giving end-of-life care include:
- A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
- B. assessing and intervening to support total management of the family and client.
- C. setting goals, expectations, and dynamic changes to care for the client.
- D. keeping all sad news away from the family and client.
Correct Answer: A
Rationale: In providing end-of-life care, nurses must possess essential competencies. Demonstrating respect and compassion, along with applying knowledge and skills in caring for both the family and the client, are crucial competencies. These skills help create a supportive and empathetic environment for individuals facing end-of-life situations. Choice B is incorrect because while assessing and intervening are important, they do not encompass the core competencies required for end-of-life care. Choice C is also incorrect; although setting goals and expectations is valuable, the primary focus should be on providing compassionate care. Choice D is incorrect as withholding sad news goes against the principles of honesty and transparency in end-of-life care.
The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible.
- B. taking care of the whole person"?body, mind, spirit, heart, and soul.
- C. no interventions are needed because the client is near death.
- D. supporting the needs of the family and client.
Correct Answer: C
Rationale: The correct goal of palliative care is to provide comprehensive care that addresses the physical, emotional, social, and spiritual needs of the dying client until the end of life. Therefore, the statement 'no interventions are needed because the client is near death' is incorrect as interventions are still essential to ensure comfort and quality of life. Choices A, B, and D are all aligned with the goals of palliative care, focusing on improving the quality of life, providing holistic care, and supporting both the family and the client.
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. measure intake and output.
- B. check albumin levels.
- C. monitor glucose levels.
- D. increase enteral feeding.
Correct Answer: A
Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.
After undergoing gastric resection, the client is informed by the nurse that which of the following meals is most likely to cause rapid emptying of the stomach?
- A. a high-protein meal
- B. a high-fat meal
- C. a large meal regardless of nutrient content
- D. a high-carbohydrate meal
Correct Answer: D
Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. On the other hand, high-fat and high-protein meals tend to delay gastric emptying. A large meal, regardless of nutrient content, can also delay gastric emptying due to the increased volume of food that needs to be processed.