Nokea
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
Correct Answer: C
Rationale: The correct next step after identifying nursing diagnoses is planning. Planning involves setting goals and creating a plan of care to address the patient's needs based on the identified nursing diagnoses. This step helps in determining interventions and outcomes for the patient. Assessment has already been completed, and diagnosis is the step where nursing diagnoses are identified. Implementation comes after planning, where the nurse carries out the planned interventions. Therefore, the logical next step in the nursing process after identifying nursing diagnoses is planning.
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During a breast examination, which finding most strongly suggests that the client has breast cancer?
- A. Slight asymmetry of the breasts
- B. A fixed nodular mass with dimpling of the overlying skin
- C. Bloody discharge from the nipple
- D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.
for pain management. When applying a new system, the nurse should:
- A. Press the system in place for 30 to 60 seconds.
- B. Choose a site on the lower torso.
- C. Shave the application site before use.
- D. Apply the system immediately after removal from a package.
Correct Answer: A
Rationale: Rationale:
A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system.
B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference.
C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system.
D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care.
Incorrect choices:
A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.
What is the rationale for giving Mr. Franco frequent mouth care?
- A. He will be thirsty considering that he is doesn’t drink enough fluids
- B. To remove dried blood when tongue is bitten during a seizure
- C. The tactile stimulation during mouth care will hasten return to consciousness
- D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
Correct Answer: B
Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco helps in removing dried blood when his tongue is bitten during a seizure, preventing infection and promoting oral hygiene. This is crucial in preventing complications and ensuring Mr. Franco's overall well-being.
Choice A is incorrect because thirst is not directly related to mouth care, and increasing fluids intake would address dehydration more effectively. Choice C is incorrect as tactile stimulation may not necessarily hasten return to consciousness in this context. Choice D is incorrect as it refers to a different issue related to mouth breathing in comatose patients, which is not the immediate concern addressed by frequent mouth care in this scenario.
The nurse knows which of the following is true about immunity?
- A. Antibody-mediated defense occurs through the T-cell system
- B. Cellular immunity is mediated by antibodies produced by the B-cells
- C. Antibodies are produced by the B-cells
- D. Lymphocytes increase with an allergic response
Correct Answer: C
Rationale: Rationale:
Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens.
Incorrect Choices:
A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity.
B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells.
D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.