Nokea
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.
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Tic douloureux is a (n) ___ cranial nerve disorder characterized by paroxysms of pain and burning sensations.
- A. 1st
- B. 7th
- C. 5th
- D. 8th
Correct Answer: C
Rationale: The correct answer is C: 5th cranial nerve. Tic douloureux, also known as trigeminal neuralgia, is characterized by severe facial pain. The trigeminal nerve, the 5th cranial nerve, is responsible for sensory input from the face. This nerve is commonly affected in cases of tic douloureux, leading to sharp, shooting pain in the face. Choices A, B, and D are incorrect because the 1st cranial nerve (olfactory nerve), 7th cranial nerve (facial nerve), and 8th cranial nerve (vestibulocochlear nerve) are not typically associated with the symptoms of tic douloureux.
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
- A. Bread
- B. Oranges
- C. Carrots
- D. Strawberries
Correct Answer: D
Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.
A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?
- A. The patient will ambulate in the hallway twice this shift using crutches correctly.
- B. Impaired physical mobility related to inability to bear weight on right leg. Provide assistance while the patient walks in the hallway twice this shift with
- C. crutches.
- D. The patient is unable to bear weight on right lower extremity.
Correct Answer:
Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly.
Rationale:
1. This choice outlines a specific nursing intervention - ambulating with crutches.
2. It includes clear actions for the patient to ambulate and specifies using crutches correctly.
3. It addresses the patient's physical mobility needs actively.
4. It focuses on promoting independence and functional ability.
Summary of other choices:
B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer.
C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation.
D: This choice only identifies the patient's condition without providing a specific nursing intervention.
Mrs. Tan was prescribed with nitroglycerin. Nurse Amalia teaches her about the common side effect of the drug which includes:
- A. High bloold pressure
- B. GIT irritation
- C. Shortness of breathing
- D. throbbing headache
Correct Answer: D
Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use.
Explanation of other choices:
A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels.
B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system.
C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
- A. Follow agency guidelines to control
- B. Review drug references
- C. Advise the client on modifying the
- D. Monitor client for depression home environment
Correct Answer: E
Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include:
E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively.
Incorrect choices:
A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder.
B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder.
C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder.
D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.