Nokea
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.
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The nurse practitioner assesses a client in the physician’s office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
- A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
- B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
- C. Weight gain, hypervigilance, hypothermia, and edema of the legs
- D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B
Rationale: The correct answer is B because the assessment findings of pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers are classic manifestations of systemic lupus erythematosus (SLE). Pericarditis can present as chest pain aggravated by deep breathing or lying flat, photosensitivity refers to skin rashes triggered by sunlight exposure, polyarthralgia involves joint pain in multiple joints, and painful mucous membrane ulcers are common in the mouth or nose. These findings align with the diagnostic criteria for SLE.
Choices A, C, and D are incorrect because they do not align with the typical presentation of SLE. Choice A includes facial erythema which is a common symptom, but the presence of profuse proteinuria, pleuritis, fever, and weight loss are not specific to SLE. Choices C and D include symptoms like weight gain, hypothermia, and edema which are not characteristic of SLE.
In summary
The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the ff. is the best evidence that the teaching has been effective?
- A. The patient states that he will be careful to avoid injury.
- B. The patient can list signs and symptoms of bleeding.
- C. The patient uses an electric razor instead of his safety razor.
- D. The patient states when he should call the doctor.
Correct Answer: C
Rationale: The correct answer is C because using an electric razor instead of a safety razor demonstrates understanding of the risk of injury associated with thrombocytopenia. This action shows practical application of the teaching to prevent bleeding. Choice A only indicates awareness but not necessarily action. Choice B shows knowledge but not necessarily application. Choice D is related to general healthcare knowledge but not directly linked to bleeding prevention in thrombocytopenia.
What should the client at risk for developing AIDS be advised to do?
- A. Abstain from anal intercourse
- B. Have a semen analysis done
- C. Have an ELISA test for antibodies
- D. Inform all sexual contacts
Correct Answer: C
Rationale: The correct answer is C because an ELISA test for antibodies is crucial to detect HIV infection early. This test can help diagnose HIV before symptoms appear, allowing for early intervention and treatment. Choice A is important but not specific to HIV prevention. Choice B is irrelevant for HIV prevention. Choice D, while important, should not take precedence over getting tested for HIV.
A newly diagnosed patient asks what asthma is. Which of the ff. explanations by the nurse is correct?
- A. “Your airways are inflamed and spastic.”
- B. “”You have fluid in your lungs that is causing shortness of breath.”
- C. “Your airways are stretched and non-functional.”
- D. “You have a low-grade infection that keeps your bronchial tree irritated.”
Correct Answer: A
Rationale: The correct answer is A because asthma is characterized by inflammation and bronchoconstriction of the airways, leading to difficulty breathing. This explanation accurately describes the pathophysiology of asthma.
Explanation for other choices:
B: Fluid in the lungs is more indicative of conditions like pneumonia or pulmonary edema, not asthma.
C: Asthma involves airway constriction and inflammation, not stretching and non-functionality.
D: Asthma is not caused by infection but rather triggered by factors like allergens or irritants.
What orders would likely be included fro a client diagnosed with multiple myeloma?
- A. Bed rest
- B. Fluid restriction
- C. Corticosteroid therapy
- D. Calcium replacement therapy
Correct Answer: C
Rationale: The correct answer is C, Corticosteroid therapy. In multiple myeloma, corticosteroids are commonly used to help reduce inflammation, suppress the immune system, and slow the growth of cancer cells. This treatment can help manage symptoms and improve quality of life for the client.
A: Bed rest is not typically prescribed for multiple myeloma unless there are specific complications requiring immobilization.
B: Fluid restriction is not a common treatment for multiple myeloma unless there is a specific need to manage fluid balance.
D: Calcium replacement therapy may be necessary in some cases of multiple myeloma due to bone involvement, but it is not a primary treatment option compared to corticosteroid therapy in managing the disease.