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The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: The correct answer is C because respiratory rate is an observable and measurable data point, making it objective. Objective data is factual and observable, such as vital signs. Choices A, B, and D are subjective data as they rely on the patient's perception or interpretation, which can be influenced by various factors and may not always be accurate or reliable. In this case, the nurse can directly measure and document the patient's respiratory rate, making it an objective piece of information.
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The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
- A. Type A
- B. Type AB
- C. Type B
- D. Type O
Correct Answer: A
Rationale: Step 1: Type A blood has been associated with a slightly higher risk of developing gastric cancer compared to other blood types.
Step 2: The nurse mentioned a 10% increase in risk, which aligns with the increased risk associated with Type A blood.
Step 3: Type AB and Type B blood do not have the same increased risk for gastric cancer as Type A blood.
Step 4: Type O blood is actually associated with a lower risk of gastric cancer compared to Type A blood.
Step 5: Therefore, the correct answer is A: Type A blood.
The couple with the lowest risk of having a child with sickle cell disease is the one in which the:
- A. Father is HbS and mother is HbS
- B. Father is HbAS and the mother is
- C. Father is HbS and mother is HbAS HbAS
- D. Father is HbA and the mother is HbS
Correct Answer: D
Rationale: The correct answer is D because sickle cell disease is an autosomal recessive genetic disorder. The disease is caused by inheriting two copies of the abnormal hemoglobin gene (HbS). In choice D, the father is HbA (normal) and the mother is HbS (carrier). This combination ensures that the child will inherit one normal gene and one abnormal gene, making them a carrier like the mother but not affected by the disease. Choices A, B, and C all involve at least one parent who carries the HbS gene, increasing the risk of the child having sickle cell disease.
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease.
Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange.
Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.
The nurse is working in a support group for client with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
- A. Avoiding the use of recreational drugs and alcohol
- B. Refraining from telling anyone about the diagnosis
- C. Following safer-sex practices
- D. Telling potential sex partners about the diagnosis, as required by the law
Correct Answer: C
Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy.
Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS.
Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent.
Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.