Nokea
The following statements are on a patient’s nursing care plan. Which statement will the nurse use as an outcome for a goal of care? The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the
- A. end of this shift.
- B. The patient will demonstrate increased tolerance to activity over the next month.
- C. The patient will understand needed dietary changes by discharge.
- D. The patient will demonstrate increased mobility in 2 days.
Correct Answer: A
Rationale: The correct answer is A because it is specific, measurable, achievable, relevant, and time-bound (SMART) - the patient verbalizing a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. This outcome is immediate, concrete, and directly related to the goal of managing pain.
Choice B is incorrect as it lacks specificity and a clear timeframe for evaluation. Choice C is incorrect because the outcome is vague and does not specify when the patient needs to understand the dietary changes. Choice D is incorrect because the timeframe is provided but the outcome is not specific enough and does not directly relate to the goal of pain management.
You may also like to solve these questions
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. Hypertension
- B. Tachycardia
- C. Oliguria
- D. Tachypnea
Correct Answer: A
Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.
A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8○0 F (38.2○0 C). What effect may this have on his need for insulin?
- A. It will have no effect.
- B. it will cause wide fluctuations in the
- C. it will decrease the need insulin. need for insulin
- D. It will increase the need for insulin.
Correct Answer: D
Rationale: The correct answer is D: It will increase the need for insulin. Infections like sinusitis and otitis media can lead to increased stress on the body, causing insulin resistance and higher blood sugar levels. This leads to an increased demand for insulin to regulate blood sugar levels effectively. Therefore, the diabetic client's need for insulin will likely increase in this scenario.
Incorrect choices:
A: It will have no effect - Incorrect because infections and fever can impact insulin requirements.
B: It will cause wide fluctuations in the need for insulin - Incorrect as infections generally lead to increased insulin needs, not fluctuations.
C: It will decrease the need for insulin - Incorrect as infections and fever typically increase insulin requirements due to increased stress on the body.
Which of the following responses indicates sympathetic nervous system function?
- A. Tachycardia, dilated pupils
- B. Hypoglycaemia, headache
- C. Increased peristalsis, abdominal cramping
- D. Pupil constriction, bronchoconstriction
Correct Answer: A
Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action.
Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.
Which food is recommended for the patient who must increase intake of potassium?
- A. Bread
- B. Potato
- C. Egg
- D. Cereal
Correct Answer: B
Rationale: The correct answer is B: Potato. Potatoes are high in potassium, which is essential for various bodily functions. Potatoes can help increase potassium intake in patients who require it. Bread, eggs, and cereal are not as rich in potassium as potatoes. Increasing intake of these foods won't provide the necessary boost in potassium levels needed for the patient.
Within 20 minutes of the start of transfusion, the client develops a sudden fever. What is the nurse’s first action?
- A. Force fluids
- B. Increase the flow rate of IV fluids
- C. Continue to monitor the vitals signs
- D. Stop the transfusion
Correct Answer: D
Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.