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The nurse is developing a plan of care for the client with multiple myeloma. The nurse includes which priority intervention in the plan of care?
- A. Encourage fluid
- B. Coughing and deep breathing
- C. Providing frequent oral care
- D. Monitoring red blood cell coun
Correct Answer: B
Rationale: A priority intervention for a client with multiple myeloma is to include coughing and deep breathing exercises in the plan of care. Multiple myeloma can affect the bone marrow's ability to produce healthy blood cells, including red blood cells, which can lead to anemia. Anemia can cause fatigue and shortness of breath. By encouraging coughing and deep breathing exercises, the nurse can help improve lung function, enhance oxygenation, and prevent potential respiratory complications in the client with multiple myeloma. This intervention is crucial in promoting respiratory health and overall well-being for the client.
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Patient Hydee asks how she could Distinguish between true and false labor? Which is NOT included among the factors in which the nurse should base her answer from?
- A. Contractions
- B. Cervical by vaginal examination
- C. Vital signs
- D. Engagement of fetus
Correct Answer: D
Rationale: The engagement of the fetus refers to the baby's head moving down into the mother's pelvis in preparation for birth. This factor is not typically used to distinguish between true and false labor because it is a sign of progress in labor rather than a defining characteristic of true labor. In contrast, the factors that are commonly used to differentiate between true and false labor include contractions (e.g., regularity, intensity, duration), cervical changes observed through vaginal examination (e.g., effacement and dilation), and monitoring vital signs.
Which additional finding confirms the diagnosis that the patient has mastitis?
- A. Enlarged glands in the axilla
- B. Normal temperature
- C. Engorged both breasts
- D. Hard mass and reddened area
Correct Answer: D
Rationale: A hard mass and a reddened area on one breast are key clinical signs that confirm the diagnosis of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, and swelling of the breast. The presence of a hard mass along with the other symptoms suggests inflammation and infection within the breast tissue. In contrast, the other findings such as enlarged glands in the axilla, normal temperature, and engorged breasts are not specific findings for mastitis and may be present in other conditions. Therefore, the presence of a hard mass and reddened area on one breast is the additional finding that strongly confirms the diagnosis of mastitis in this case.
A patient is reluctant to discuss personal health issues due to embarrassment. What is the nurse's best approach to encourage open communication?
- A. Dismiss the patient's concerns and proceed with asking personal health questions.
- B. Provide the patient with privacy and assurance of confidentiality to create a safe space for discussion.
- C. Ignore the patient's reluctance and proceed with asking personal health questions regardless.
- D. Tell the patient that embarrassment is unnecessary and they should be open about their health issues.
Correct Answer: B
Rationale: Providing the patient with privacy and assurance of confidentiality is essential to create a safe and trusting environment for open communication. By assuring the patient that their information will be kept confidential, the nurse can help alleviate the patient's fears and encourage them to feel more comfortable discussing their personal health issues. Dismissing the patient's concerns (option A), ignoring their reluctance (option C), or telling them that their embarrassment is unnecessary (option D) are not effective approaches and may further hinder open communication. It is crucial for the nurse to create a supportive and nonjudgmental atmosphere to build trust with the patient and facilitate honest discussions about their health concerns.
You are a Drug Abuse Treatment and Rehabilitation Center Nurse. During the assessment of a newly admitted Person Who Uses Drugs (PWUDs) named Korino, which of the following is the MOST APPROPRIATE question to ask?
- A. Ask Korino how long he thought that he could take drugs without someone finding it.
- B. Ask Korino why he started taking illegal drugs.
- C. Not ask any questions for fear Korino will deny and may become assaultive.
- D. Ask Korino about the amount of drug used and its effect and how long he had been using.
Correct Answer: D
Rationale: The most appropriate question to ask during the assessment of a newly admitted Person Who Uses Drugs (PWUDs) like Korino is to ask about the amount of drug used, its effects, and how long he has been using. This question provides valuable information for treatment planning and understanding the extent of Korino's drug use. By asking about the specific details of his drug use, the nurse can assess the severity of the addiction, potential health risks, and the duration of substance abuse. This information is crucial for developing an individualized treatment plan and providing appropriate care for Korino's needs. Asking open-ended questions about drug use also helps build rapport and trust between the nurse and the patient, which is essential for effective treatment.
A postpartum client with a history of gestational diabetes expresses concern about managing blood sugar levels while breastfeeding. What nursing intervention should be prioritized to address the client's concerns?
- A. Educating the client about the importance of balanced nutrition and frequent monitoring of blood glucose levels
- B. Recommending insulin supplementation to maintain target blood sugar levels
- C. Encouraging the client to avoid breastfeeding to prevent fluctuations in blood sugar levels
- D. Referring the client to a dietitian for a specialized postpartum meal plan
Correct Answer: A
Rationale: Educating the client about the importance of balanced nutrition and frequent monitoring of blood glucose levels should be prioritized to address the client's concerns about managing blood sugar levels while breastfeeding. This intervention helps empower the client to make informed choices about her diet and monitor her blood sugar levels effectively. By focusing on balanced nutrition and regular blood glucose monitoring, the client can better manage her blood sugar levels during the postpartum period and while breastfeeding, reducing the risk of complications associated with gestational diabetes. It also promotes overall health and well-being for both the mother and the baby.