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One evening, Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse's INITIAL intervention?
- A. Give PRN medication.
- B. Refer patient to the physician.
- C. Assess the patency of the tubing.
- D. Re-assess the patient.
Correct Answer: C
Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.
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What is the M0ST APPROPRIATE nursing diagnosis for this patient?
- A. Self-care deficit related to neuromuscular impairment.
- B. Alteration in nutritional status related to possible choking .
- C. Alteration in nutritional status related to anorexia.
- D. Alteration in urinary elimination related to sensory motor impairment.
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.
A woman in active labor has a prolonged second stage with inadequate expulsive efforts. What nursing intervention is appropriate to facilitate fetal descent?
- A. Encourage the mother to push forcefully during contractions.
- B. Apply fundal pressure to assist with fetal descent.
- C. Prepare for immediate cesarean section.
- D. Administer intravenous magnesium sulfate for uterine relaxation.
Correct Answer: B
Rationale: In the scenario of a woman in active labor experiencing a prolonged second stage with inadequate expulsive efforts, the appropriate nursing intervention to facilitate fetal descent would be to apply fundal pressure. Fundal pressure, or applying pressure on the upper abdomen just above the uterine fundus, can help in directing the fetal head downwards and aiding in the descent through the birth canal. It is important to note that fundal pressure should be applied carefully and with proper technique to prevent excessive force that could potentially harm the mother or the baby. Encouraging the mother to push forcefully during contractions can be helpful, but the addition of fundal pressure can provide extra assistance in cases of inadequate progress. Immediate cesarean section may be considered if other interventions are unsuccessful or if there are concerns for fetal distress. Administering intravenous magnesium sulfate for uterine relaxation is not indicated in this situation.
The diagnostic examination for osteoporosis is geared towards measuring
- A. Bone density
- B. Weight
- C. Blood volume
- D. Height
Correct Answer: A
Rationale: The diagnostic examination for osteoporosis typically involves measuring bone density. This is usually done through a dual-energy x-ray absorptiometry (DEXA) scan, which is considered the gold standard for assessing bone density. Osteoporosis is characterized by decreased bone mass and deterioration of bone tissue, leading to increased bone fragility and risk of fractures. Measuring bone density helps in diagnosing osteoporosis by identifying areas of low bone density, assessing the risk of fractures, and monitoring the effectiveness of treatment. Weight, blood volume, and height are not directly used as primary indicators for diagnosing osteoporosis.
A patient has been advised by the psychiatrist that he needs inpatient hospitalization. The patient agrees, signs the admission forms, and agrees to receive treatment. What type of admission is this?
- A. Formal
- B. Informal
- C. Voluntary
- D. Involuntary
Correct Answer: C
Rationale: This type of admission is considered voluntary because the patient willingly agrees to be admitted to the hospital for treatment. The patient has signed the admission forms and consented to receive the necessary care, indicating a willingness to participate in their treatment plan. In a voluntary admission, the individual retains the right to make decisions about their treatment and can choose to leave the hospital against medical advice if they wish to do so.
Patient Benito ask5 Nurse Virgo, "Why can't the surgeon just take out my pancreas?" The BEST response of Nurse Virgo is
- A. "your body needs to function well with your pancreas "
- B. "your attack will soon be overcome when you are at rest"
- C. "if your pancreas is removed, you can never eat fat and fried foods again"
- D. "antibiotic wil1 relieve signs of infection"
Correct Answer: A
Rationale: The best response of Nurse Virgo is to explain to Patient Benito that his body needs to function well with his pancreas. The pancreas plays a critical role in the digestive system by producing digestive enzymes and hormones that help regulate blood sugar levels. Removing the pancreas would result in serious health consequences and complications, as the body relies on it for essential functions. It is important for the patient to understand the significance of the pancreas and why its removal is not a viable solution.