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The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.”
Correct Answer: B
Rationale: The correct answer is B. Polymyositis can affect muscles involved in swallowing, leading to aspiration risk. Therefore, it's crucial for the client to exhibit no signs or symptoms of aspiration. Choice A is unrelated to polymyositis. Choice C involves issues with muscle weakness rather than aspiration risk. Choice D relates to cognitive function, not a common issue with polymyositis.
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Which nursing diagnosis is most appropriate for a client with Addison’s disease?
- A. Risk for infection
- B. Urinary retention
- C. Excessive fluid volume
- D. Hypothermia
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving.
A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient.
B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions.
C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to assess the patient's condition promptly after being informed of feeling dizzy and light-headed. Assessment involves collecting data to identify actual or potential health problems. By not promptly assessing the patient's worsening condition, the nurse missed an essential step in the nursing process.
Choice B: Diagnosis comes after assessment and involves identifying the patient's health problems based on collected data. Choice C: Implementation is the phase where the nurse carries out the plan of care. Choice D: Evaluation occurs after implementation to determine if the interventions were effective.
A client is hospitalized with oat cell carcinoma of the lung. To manage severe pain, the physician prescribes a continuous I.V. infusion of morphine. Which formula should the nurse use to check that the morphine dose is appropriate for the client?
- A. 1 mg/kg of body weight
- B. 5 mg/70kg of body weight
- C. 5 mg/kg of body weight
- D. 10mg/70kg of body weight
Correct Answer: C
Rationale: The correct formula to calculate the appropriate morphine dose for the client is 5 mg/kg of body weight. This is the most suitable formula because morphine dosing is typically based on weight to ensure appropriate pain management and to prevent adverse effects. By using this formula, the nurse can calculate the exact dose based on the client's weight, providing personalized care.
Choice A (1 mg/kg of body weight) is too low of a dose and may not effectively manage severe pain. Choice B (5 mg/70kg of body weight) is not ideal as it does not account for variations in weight among individuals. Choice D (10mg/70kg of body weight) would result in an overdose for most patients, potentially causing serious harm.
Therefore, by using the formula of 5 mg/kg of body weight, the nurse can ensure that the morphine dose is appropriate and safe for the client.
The nurse observes the temperature record of a client and relates the fever to the brain infection the client currently has. The nurse knows that a high temperature may lead to an increased cerebral irritation. Which of the ff measures can help the nurse control the clients body temperature? Choose all that apply
- A. Providing tepid sponge bath
- B. Applying ice packs
- C. Administering prescribed antipyretics
- D. Keeping the room temperature warm
Correct Answer: A
Rationale: The correct answer is A: Providing tepid sponge bath. This measure helps lower body temperature through evaporation of water from the skin. It is effective in managing fever without causing shivering or discomfort. Ice packs (B) can lead to vasoconstriction and shivering, raising body temperature. Antipyretics (C) are drugs that can reduce fever but may not address the underlying cause. Keeping the room warm (D) can exacerbate fever by hindering heat dissipation.