Nokea
Of the following information collected during a nursing assessment, which are subjective data?
- A. vomiting, pulse 96
- B. respirations 22, blood pressure 130/80
- C. nausea, abdominal pain
- D. pale skin, thick toenails
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be measured or observed directly. In this case, nausea and abdominal pain are symptoms that can only be described by the patient, making them subjective data. Vomiting, pulse rate, respirations, blood pressure, pale skin, and thick toenails are all objective data, as they can be measured or observed directly by the healthcare provider. Therefore, choice C is the correct answer as it represents subjective data.
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An adult is receiving NSAID. Which of the following would the nurse include in the teaching about this medication?
- A. Take NSAID with aspiring for full effect
- B. Take the NSAID with meals
- C. Orange juice will help to potentiate the effect of NSAID
- D. The NSAID will coat the stomach lining
Correct Answer: B
Rationale: The correct answer is B: Take the NSAID with meals. Taking NSAIDs with meals helps reduce stomach irritation and risk of developing ulcers. Food acts as a protective barrier and helps in the absorption of the medication.
Incorrect Choices:
A: Taking NSAID with aspirin can increase the risk of stomach irritation and bleeding due to combined antiplatelet effects.
C: Orange juice does not potentiate the effect of NSAIDs and may even worsen stomach irritation due to its acidity.
D: NSAIDs do not coat the stomach lining; in fact, they can irritate the stomach lining and increase the risk of ulcers.
Which of the following groups of terms best describes a nurse-initiated intervention?
- A. Dependent, physician-ordered, recovery
- B. Autonomous, clinical judgment, client outcomes
- C. Medical diagnosis, medication administration
- D. Other health care providers, skill acquisition
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
- A. Increased ICP
- B. Parasympathetic response
- C. Sympathetic response
- D. Increased cerebral blood flow
Correct Answer: A
Rationale: The correct answer is A: Increased ICP. Decreasing level of consciousness is a classic sign of increased intracranial pressure (ICP) due to the compression of the brain. As ICP rises, it impairs cerebral perfusion leading to altered mental status. Parasympathetic response (B) and sympathetic response (C) are related to autonomic nervous system functions, not consciousness. Increased cerebral blood flow (D) might lead to conditions like hyperemia but does not directly cause a decreased level of consciousness.
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
- A. “Data interpretation occurs before data validation.”
- B. “Validation involves looking for patterns in professional standards.”
- C. “Validation involves comparing data with other sources for accuracy.”
- D. “Data interpretation involves discovering patterns in professional standards.”
Correct Answer: C
Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This process helps in identifying any discrepancies or errors in the data. By cross-referencing with other sources, the nurse can verify the correctness of the data.
Rationale:
1. Data validation checks the accuracy of the data by comparing it with external sources.
2. Data interpretation involves analyzing and making sense of the data, not comparing it with other sources.
3. Option A is incorrect because data validation typically comes after data collection and precedes data interpretation.
4. Option B is incorrect as validation does not specifically involve looking for patterns in professional standards.
5. Option D is incorrect because data interpretation focuses on understanding trends and insights from the data, not patterns in professional standards.
Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle
- A. Abnormal distribution of body hair
- B. Lifetime dependency on hormone replacement
- C. The need to drink many fluids to replace those lost
- D. The need to undergo repeat surgical procedures
Correct Answer: B
Rationale: The correct answer is B: Lifetime dependency on hormone replacement. After hypophysectomy, the pituitary gland is removed, leading to a deficiency in essential hormones. Patients will need lifelong hormone replacement therapy to maintain normal body functions. This is crucial for regulating metabolism, growth, reproduction, and stress response. Choices A, C, and D are incorrect because abnormal distribution of body hair, increased fluid intake, and repeat surgical procedures are not typically associated with hypophysectomy. It is essential to focus on the long-term management of hormone replacement therapy to ensure the patient's overall health and well-being.