Nokea
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: C
Rationale: The correct answer is C: Maintaining the integrity of the urinary system. This is crucial in preoperative preparation for a client with malignant tumors to prevent complications such as urinary obstruction or infection. Assessing symptoms of peritonitis (B) is important but not as critical as ensuring urinary system integrity. Insertion of an ostomy pouch (A) and nasogastric tube diversion procedure (D) may be necessary interventions for some cases, but they are not as essential as ensuring the urinary system's integrity to prevent serious complications.
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A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: The correct answer is A: Expressive aphasia and paralysis on the right side of the body. In a right-handed person, the left side of the brain controls language and right-sided motor function. A stroke affecting the left side of the cortex would lead to expressive aphasia due to damage to Broca's area, causing difficulty in speaking and forming words. Paralysis on the right side of the body would result from damage to the motor cortex in the left hemisphere. Choices B, C, and D are incorrect because they do not align with the typical deficits seen in a person with a stroke affecting the left side of the cortex in a right-handed individual.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be observed or measured by others. In this case, choice C is correct because the patient describing excitement about discharge is personal and based on the patient's feelings or perceptions. This is subjective data because it is based on the patient's own experiences and emotions. Choices A and B are incorrect because patient's temperature and wound appearance are objective data that can be measured or observed by the nurse. Choice D is also incorrect as patient pacing the floor is an observable behavior, making it objective data. Therefore, choice C is the correct answer as it represents subjective data in the context of the assessment.
A 40 year old woman with aplastic anemia is prescribed estrogen with progesterone. The nurse can expect that these medications are given for which of the following reasons?
- A. To stimulate bone growth
- B. To enhance sodium and potassium
- C. To regulate fluid balance absorption
- D. To promote utilization and storage of fluids
Correct Answer: A
Rationale: The correct answer is A: To stimulate bone growth. Estrogen and progesterone are hormones that play a crucial role in maintaining bone density and promoting bone growth. In postmenopausal women or individuals with conditions like aplastic anemia, bone health can be compromised. Estrogen helps in preventing bone loss and maintaining bone strength, while progesterone also contributes to bone formation. Therefore, in this scenario, these medications are likely prescribed to help improve bone health in the woman with aplastic anemia.
Incorrect choices:
B: Estrogen and progesterone do not directly enhance sodium and potassium levels.
C: Estrogen and progesterone do not regulate fluid balance absorption directly.
D: Estrogen and progesterone do not specifically promote utilization and storage of fluids.
Mrs. Diwa has been diagnosed with systemic lupus erythematosus, the nurse upon assessment can expect to find which of the following?
- A. dysphagia
- B. dryness or itching of genitalia
- C. decreased visual acuity or blindness
- D. abnormal lung sounds
Correct Answer: D
Rationale: The correct answer is D because systemic lupus erythematosus can lead to inflammation in the lungs, causing abnormal lung sounds. Dysphagia (choice A) is not typically associated with lupus. Dryness or itching of genitalia (choice B) is more characteristic of conditions like yeast infections or dermatitis. Decreased visual acuity or blindness (choice C) is not a common manifestation of lupus. Abnormal lung sounds (choice D) are commonly seen in lupus patients due to inflammation and possible lung involvement.