Nokea
Nursing diagnosis commonly used when working with Sandro is
- A. ineffective role performance
- B. Compromised family coping
- C. impaired social interaction
- D. risk for injury.
Correct Answer: C
Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.
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A nurse is preparing to assist with a magnetic resonance imaging (MRI) procedure for a patient. What action should the nurse prioritize to ensure procedural safety?
- A. Screening the patient for contraindications to MRI, such as metal implants or claustrophobia
- B. Administering intravenous sedation to the patient before the procedure
- C. Placing the patient in a supine position with arms at their sides during the MRI scan
- D. Allowing the patient to wear metallic jewelry or accessories during the procedure
Correct Answer: A
Rationale: The nurse should prioritize screening the patient for contraindications to MRI, such as metal implants or claustrophobia, to ensure procedural safety. Metallic objects can be hazardous in an MRI environment as they can be attracted to the magnet, potentially causing harm to the patient or staff. Claustrophobia can also be a significant issue for patients undergoing an MRI scan, and identifying this beforehand allows for appropriate measures to be taken to address the patient's anxiety or discomfort. Prioritizing this screening step helps ensure the safety and well-being of the patient during the MRI procedure.
In taking the patient's history from the mother, the nurse should ask the mother information related to the daughters' __________.
- A. Schooling
- B. Pregnancy
- C. Menarche
- D. Immunization
Correct Answer: C
Rationale: The nurse should ask the mother information related to their daughter's menarche. Menarche refers to the first occurrence of menstruation in a girl, which is an important milestone in her development. By inquiring about the daughter's menarche, the nurse can gather essential information about the daughter's reproductive health, growth, and development. This allows the nurse to assess whether the daughter's menstrual cycle is regular and if there are any concerns related to her reproductive health. Understanding the daughter's menarche history is vital in providing appropriate healthcare and support for her.
Verbal communication is the use of words when talking to your patient. The use of literal words when you speak is the :
- A. Understandable phrases
- B. The circumstances
- C. Content
- D. Understandable sentences
Correct Answer: C
Rationale: Verbal communication involves the use of words and language to convey information. The content refers to the actual words and messages being communicated. In verbal communication with your patient, the content of what you say is key to ensuring effective communication that is clear, accurate, and easily understood. Therefore, the use of literal words when speaking to your patient embodies the content of your communication.
A patient presents with a palpable, non-tender mass in the right neck, just below the angle of the mandible. Ultrasound imaging demonstrates a well-defined, hypoechoic lesion with cystic components. Which of the following conditions is most likely responsible for this presentation?
- A. Branchial cleft cyst
- B. Thyroglossal duct cyst
- C. Lymphadenopathy
- D. Parotid gland tumor
Correct Answer: A
Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.
A patient presents with chest pain, dyspnea, and a history of recent surgery or trauma. An echocardiogram reveals a large pericardial effusion with right ventricular collapse during diastole. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Pericardial effusion
- C. Myocardial infarction
- D. Aortic dissection
Correct Answer: B
Rationale: The cardiovascular disorder most likely responsible for the symptoms described is a pericardial effusion. A pericardial effusion is an accumulation of fluid within the pericardial space surrounding the heart. When a large pericardial effusion is present, it can lead to compression of the heart chambers, resulting in symptoms such as chest pain and dyspnea.