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Nurse Kara 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. Washing feet in hot water is not part of diabetic foot care as it can lead to burns or skin damage. A: Properly fitting shoes help prevent injuries. B: Trimming toenails straight reduces risk of ingrown nails. D: Wearing shoes on hot surfaces protects feet from burns or injuries. Overall, C is incorrect due to its potential harm to the client's feet.
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Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: The correct answer is A: Age-related changes. Older clients are more susceptible to immune system disorders due to age-related changes such as a weakened immune response, increased inflammation, and decreased production of immune cells. Providing special care is important to address these specific vulnerabilities.
Incorrect choices:
B: Use of multiple drugs (Polypharmacy) - While polypharmacy can impact the immune system, it is not the primary factor for providing special care to older clients with immune system disorders.
C: Poor diet - While diet plays a role in overall health, it is not the main factor necessitating special care for older clients with immune system disorders.
D: Reduced activity levels - Although physical activity is important for overall health, reduced activity levels are not the primary reason for providing special care to older clients with immune system disorders.
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards?
- A. Professional physicians’ organizations
- B. State Nurse Practice Acts
- C. The Joint Commission
- D. The Agency for Health Care Research and Quality
Correct Answer: B
Rationale: Correct Answer: B (State Nurse Practice Acts)
Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care.
Summary of Incorrect Choices:
A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice.
C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice.
D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.
A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?
- A. Abdominal pain
- B. Serous drainage from the incision
- C. Hypoactive bowel sounds
- D. Shallow breathing and increasing lethargy
Correct Answer: D
Rationale: The correct answer is D - Shallow breathing and increasing lethargy. This could indicate a potential complication such as respiratory distress or postoperative infection. Shallow breathing may suggest respiratory compromise, while increasing lethargy could be a sign of systemic infection or inadequate oxygenation.
A: Abdominal pain is common postoperatively and can be managed with pain medication.
B: Serous drainage from the incision is normal and expected in the early postoperative period.
C: Hypoactive bowel sounds are common after abdominal surgery due to anesthesia and manipulation of the bowel; it typically resolves as the patient recovers.
In summary, the other options are common postoperative findings, while shallow breathing and increasing lethargy are concerning signs that require immediate attention.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data are measurable and observable, such as vital signs. Respirations of 16 are a specific numerical measurement that can be quantified. This makes choice C the correct answer as it is factual and quantifiable. Choices A, B, and D are subjective data, as they rely on the patient's feelings or experiences, which are open to interpretation and not measurable. Therefore, the nurse should report choice C as objective data as it provides concrete information for assessment and decision-making.
A seizure characterized by loss of consciousness and tonic spasms of the trunk and extremities rapidly followed by repetitive generalized clonic jerking is classified as:
- A. Focal seizure
- B. Jacksonian seizure
- C. Generalized seizure
- D. Partial seizure
Correct Answer: C
Rationale: The correct answer is C: Generalized seizure. This type of seizure involves both hemispheres of the brain from the onset, leading to loss of consciousness and tonic-clonic jerking. It is characterized by widespread, synchronized electrical discharges.
A: Focal seizures start in one area of the brain, leading to localized symptoms without loss of consciousness.
B: Jacksonian seizures are a type of focal seizure characterized by a progression of jerking movements from one body part to another.
D: Partial seizures involve only one part of the brain, leading to localized symptoms or altered consciousness without loss of awareness.