The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
- A. The nurse provides assistance while the patient is walking in the hallways.
- B. The patient is able to ambulate in the hallway with crutches.
- C. The patient will deny pain while walking in the hallway.
- D. The patient’s level of mobility will improve.
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery.
A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
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A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
- A. Maintain standard precautions
- B. Prepare for the possibility that the baby may be delivered by CS.
- C. Notify the obstetrician and nurse midwife about the vesicles as soon as possible.
- D. Apply antibiotic ointment to the vesicles and place the mother in reverse isolation
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor.
2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences.
3. Standard precautions should always be maintained to prevent the spread of infections.
4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
- A. Ask for at least two other assistive personnel to come to the room.
- B. Medicate the patient to alleviate discomfort while ambulating.
- C. Review the patient’s activity orders.
- D. Offer the patient a walker.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Safety: Morbidly obese patients are at higher risk of falls during transfers.
2. Assistance: Having two other personnel ensures safe transfer.
3. Weight distribution: Distributing the patient's weight among multiple helpers reduces strain.
4. Proper body mechanics: Allows for proper positioning and technique while assisting.
Summary of why other choices are incorrect:
B. Medication doesn't address the safety concern of transferring a morbidly obese patient.
C. Reviewing activity orders is not the immediate action needed for the patient's first bathroom transfer.
D. Offering a walker may not provide sufficient support for a morbidly obese patient during the transfer.
Hyperparathyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
- A. Heat intolerance and systolic
- B. Diastolic hypertension and widened hypertension pulse pressure
- C. Weight gain and heat intolerance
- D. Anorexia and hyper-excitability
Correct Answer: A
Rationale: The correct answer is A because hyperparathyroidism is not caused by increased levels of thyroxine but by overactivity of the parathyroid glands. This would lead to symptoms of heat intolerance due to increased metabolism and systolic hypertension due to the effects of excess parathyroid hormone on calcium levels.
Choice B is incorrect because diastolic hypertension and widened pulse pressure are not typical symptoms of hyperparathyroidism. Choice C is incorrect because weight gain is not a common symptom of hyperparathyroidism. Choice D is incorrect because anorexia and hyper-excitability are not typical symptoms of hyperparathyroidism.
A client is receiving chemotherapy for cancer. The nurse reviews the client’s laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
- A. Activity intolerance
- B. Impaired tissue integrity
- C. Impaired oral mucous membranes
- D. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Correct Answer: D
Rationale: The correct answer is D: Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Thrombocytopenia is a low platelet count, which can lead to impaired blood clotting and potential bleeding. Ineffective tissue perfusion is the most critical concern as it can lead to life-threatening complications like hemorrhage. Activity intolerance, impaired tissue integrity, and impaired oral mucous membranes are important but do not pose an immediate threat to the client's life compared to the risk of hemorrhage from thrombocytopenia.
Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:
- A. bradycardia, weight loss, heart failure, diarrhea
- B. tachycardia, constipation, exopthalmus
- C. lethargy, weight gain, slow speech, decreased RR
- D. hypothermia, weight loss, increased RR
Correct Answer: C
Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.