Nokea
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on the potential causes of their fatigue, leading to a more detailed and insightful response. This open-ended question allows the patient to explore various factors contributing to their fatigue, such as lifestyle habits, medical conditions, or emotional stressors.
Choice A focuses on stress, which may not be the primary cause of fatigue for the patient. Choice C is too specific and may not uncover other relevant information. Choice D assumes that sleep duration is the sole factor contributing to fatigue, neglecting other possible causes. Overall, choice B facilitates a more comprehensive discussion and helps the nurse gather valuable information to address the patient's concerns effectively.
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When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: The correct answer is C: Amount and color of sinus drainage. Assessing the amount and color of sinus drainage is crucial in evaluating the effectiveness of nursing interventions for sinusitis discomfort as it indicates the presence of infection or inflammation. Changes in color or amount can signify improvement or worsening of the condition. WBC count (A) may indicate infection but doesn't directly reflect sinusitis discomfort. Capillary refill (B) assesses circulation, not sinusitis. Comfort level (D) is subjective and can vary among individuals, making it less reliable for assessing the effectiveness of interventions.
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
- A. “ Right after the operation, I will wear the pneumatic compression device while sitting on the chair.”
- B. “I will not eat anything after 12 pm the night befire my operation, but I sure can drink.”
- C. “The skin preparation site is longer and wider than the actual incision site.”
- D. “I will need to sign the consent from after I get to the operating table.”
Correct Answer: B
Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications.
A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations.
C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process.
D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing.
In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.
Hypernatremia is associated with a:
- A. Serum osmolality of 245mOsm/kg
- B. Urine specific gravity below 1.003
- C. Serum sodium of 150mEq/L
- D. Combination of all of the above
Correct Answer: D
Rationale: Step 1: Hypernatremia is defined by elevated serum sodium levels (>145mEq/L).
Step 2: Serum osmolality of 245mOsm/kg is high, consistent with hypernatremia.
Step 3: Urine specific gravity below 1.003 indicates dilute urine, a common finding in hypernatremia.
Step 4: The combination of elevated serum sodium, high serum osmolality, and low urine specific gravity confirms hypernatremia.
Summary:
A: Incorrect, as high serum osmolality (not 245mOsm/kg) is associated with hypernatremia.
B: Incorrect, as low urine specific gravity (not below 1.003) is seen in hypernatremia.
C: Incorrect, as serum sodium needs to be >145mEq/L to indicate hypernatremia.
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
- A. Place the arm in the sling
- B. Apply cold soaks to the affected arm
- C. Introduce variations in styles of clothing
- D. Tie a tight bandage to the arm
Correct Answer: C
Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm.
A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality.
B: Applying cold soaks may help with swelling but does not directly address the client's self-image.
D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.
A patient is treated with IV methylprednisolone (Solu-medrol) for emphysema. What is the purpose of corticosteroid treatment in lung disease?
- A. Dry secretions
- B. Improve the oxygen-carrying capacity
- C. Treat the infection that causes an of hemoglobin.
- D. Reduce airway inflammation.
Correct Answer: D
Rationale: The correct answer is D: Reduce airway inflammation. Corticosteroids like methylprednisolone are used in emphysema to reduce inflammation in the airways, which can help improve lung function and symptoms. Corticosteroids work by suppressing the immune response that leads to inflammation in the airways. This can help decrease swelling, mucus production, and constriction of the airways, all of which contribute to the symptoms of emphysema. Dry secretions (choice A) and improving oxygen-carrying capacity (choice B) are not the primary purposes of corticosteroid treatment in emphysema. Treating infection that causes a low level of hemoglobin (choice C) is not relevant to corticosteroid treatment for emphysema.