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Priority nursing diagnosis on the patient who was admitted with acute renal failure
Priority nursing diagnosis on the patient who was admitted with acute renal failure would be:
- A. Bed rest to conserve oxygen.
- B. Increase fluid intake to promote urination.
- C. Fatigue due to altered nutrition.
- D. Dehydration secondary to diuresis.
Correct Answer: C
Rationale: Fatigue due to altered nutrition is a priority in acute renal failure as it reflects metabolic imbalances and nutritional deficits.
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As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
- A. Decreased appetite
- B. Inadequate fluid intake
- C. Prolonged gastric emptying
- D. Reduced intestinal motility
Correct Answer: D
Rationale: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.
Thirty minutes after delivery the nurse finds that a mother's uterus is relaxed and the lochia is excessive.
The fist action by the nurse should be to:
- A. Check the mother's vital signs.
- B. Elevate the foot part of the bed.
- C. Immediately notify the physician.
- D. Massage the mother's uterus and expel any clots.
Correct Answer: D
Rationale: Massaging the uterus promotes contraction, reducing excessive lochia and preventing hemorrhage.
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care
A primary belief of psychiatric mental health nursing is:
- A. most people have the potential to change and grow.
- B. every person is worthy of dignity and respect.
- C. human needs are individual to each person.
- D. some behaviors have no meaning and cannot be understood.
Correct Answer: B
Rationale: The belief that every person is worthy of dignity and respect is foundational to psychiatric mental health nursing, emphasizing client-centered care. The other options are also relevant but not the primary belief highlighted here. Psychosocial Integrity
A patient with a diagnosis of bipolar disorder has been drinking copious amounts of water and voiding frequently. The patient is experiencing muscle cramps, twitching, and is reporting dizziness.
The nurse checks lab work for
- A. complete blood count results, particularly the platelets.
- B. electrolytes, particularly the serum sodium.
- C. urine analysis, particularly for the presence of white blood cells.
- D. EEG.
Correct Answer: B
Rationale: Symptoms suggest hyponatremia from excessive water intake, requiring electrolyte assessment.