Nokea
The nurse is reviewing information about a client and notes the following documentation: 'Client is confused.' The nurse recognizes this information is an example of what?
- A. Subjective data
- B. A data cue
- C. An inference
- D. Primary data
Correct Answer: C
Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.
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The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. “It will raise you BP, which is necessary because of blood loss.”
- B. “It will dilate your bronchioles and make your breathing easier.”
- C. “It will help your blood to clot to reduce bleeding.”
- D. “It will constrict your vessels and slow down the bleeding.”
Correct Answer: D
Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.
Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?
- A. Bruising around the operative site
- B. Pain
- C. Irritability
- D. Fever
Correct Answer: D
Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: The correct answer is B: Fine needle aspiration. This is because fine needle aspiration involves extracting cells from the lump in the breast for examination under a microscope to determine if they are cancerous. This procedure provides a definitive diagnosis of breast cancer. Breast self-examination (A) is a screening tool for detecting lumps but does not confirm a diagnosis. Mammography (C) is used for screening and detecting abnormalities but requires further testing for confirmation. Chest x-ray (D) is not useful for diagnosing breast cancer.
A patient who was walking in the woods disturbed a beehive, was stung, and was taken to the emergency department immediately due to allergies to bee stings. Which of the ff. symptoms would the nurse expect to see upon admission of this patient? i.Pallor around the sting bites iv. Retinal hemorrhage ii.Numbness and tingling in the extremities v. Tachycardia iii.Respiratory stridor vi. Dyspnea
- A. 1, 2, 2004
- B. 3, 5, 2006
- C. 2, 3, 2004
- D. 4, 5, 2006
Correct Answer: D
Rationale: The correct answer is D: 4, 5, 2006. Upon admission, a patient with allergies to bee stings may exhibit tachycardia (increased heart rate) due to an allergic reaction. Respiratory stridor (high-pitched wheezing) may occur as a sign of airway inflammation. Retinal hemorrhage and dyspnea (difficulty breathing) are not typically associated with bee sting allergies. Pallor and numbness/tingling are also not common symptoms in this scenario. Therefore, choices A, B, and C are incorrect.
A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he 'can’t live with this fear.' Which of the following diagnoses for this client is correctly written?
- A. Post-trauma syndrome related to being attacked
- B. Psychological overreaction related to being attacked
- C. Needs assistance coping with attack
- D. Mental distress related to being attacked
Correct Answer: A
Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. Post-trauma syndrome encompasses a range of symptoms following a traumatic event, such as flashbacks, anxiety, and emotional distress. The other choices are incorrect because they are either too vague (B: Psychological overreaction) or do not capture the specific nature of the client's symptoms (C: Needs assistance coping; D: Mental distress). Therefore, option A is the most appropriate diagnosis based on the client's presentation.