Nokea
The nurse reviews the patient 's plan of care. Which of the following nursing diagnose will be the PRIORITY?
- A. Fluid volume, deficit
- B. Risk for pain, acute
- C. Coping, ineffective
- D. Body image, disturbed
Correct Answer: A
Rationale: In prioritizing nursing diagnoses, the nurse should consider issues that pose the greatest risk to the patient's immediate well-being. A fluid volume deficit can lead to dehydration and potentially life-threatening complications, making it a priority to address. It is crucial to restore fluid balance to maintain normal body functions and prevent further deterioration of the patient's condition. Ensuring adequate hydration is essential for the patient's overall health and recovery. The other options, such as risk for pain, coping, and body image disturbances, while important, are not as urgent as addressing a fluid volume deficit.
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Nurse Rosa is able to know the patterns of occurrence and distribution of diseases in the community . Per record she found out there had been cases of rabies at irregular intervals scattered in particular places. This occurrence rates to ______.
- A. Endemic
- B. Pandemic
- C. Epidemic
- D. Sporadic
Correct Answer: D
Rationale: The occurrence of rabies at irregular intervals scattered in particular places indicates a sporadic pattern. Sporadic diseases are those that occur infrequently and irregularly in a population. These diseases do not have a consistent pattern of occurrence and are not confined to a specific geographic area or population group. In this case, the cases of rabies being reported at irregular intervals and scattered in particular places suggest a sporadic distribution rather than an endemic (constantly present in a population), epidemic (sudden increase in cases in a specific population), or pandemic (global spread of a disease) pattern.
A patient presents with acute onset of severe headache, visual disturbances, and vomiting. Imaging reveals a tumor compressing the optic chiasm. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Meningioma
- B. Glioblastoma multiforme
- C. Pituitary adenoma
- D. Medulloblastoma
Correct Answer: C
Rationale: A pituitary adenoma is a type of benign tumor that arises from the pituitary gland, which is located at the base of the brain. When a pituitary adenoma grows large enough, it can compress surrounding structures, including the optic chiasm – the point at which the optic nerves cross over in the brain. Compression of the optic chiasm can lead to symptoms such as vision problems (e.g., visual disturbances), headaches, and nausea/vomiting, which are consistent with the presentation described in the question. Meningiomas, glioblastoma multiforme, and medulloblastomas are less likely to compress the optic chiasm and present with different characteristic symptoms based on their locations and growth patterns.
Which of the following structures is responsible for producing digestive enzymes and bicarbonate-rich pancreatic juice, which are essential for the digestion of carbohydrates, fats, and proteins in the small intestine?
- A. Liver
- B. Gallbladder
- C. Pancreas
- D. Spleen
Correct Answer: C
Rationale: The pancreas is the structure responsible for producing digestive enzymes and bicarbonate-rich pancreatic juice. These enzymes aid in the breakdown of carbohydrates, fats, and proteins in the small intestine to facilitate the absorption of nutrients. The pancreas plays a crucial role in the process of digestion, making it an essential organ in the digestive system. The liver is primarily involved in producing bile to aid in the digestion of fats, the gallbladder stores bile produced by the liver, and the spleen is involved in filtering the blood and storing blood cells.
A patient with advanced dementia is no longer able to communicate verbally and displays signs of distress. What should the palliative nurse consider when assessing and managing the patient's distress?
- A. Focus solely on physical comfort measures to alleviate distress.
- B. Assume the patient's distress is solely related to physical discomfort.
- C. Explore non-verbal cues and behaviors to identify the underlying causes of distress.
- D. Administer sedative medications to manage the patient's agitation.
Correct Answer: C
Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.
Nurse Bea recall the theory or Nursing as caring by ______.
- A. Orem
- B. Kings
- C. Watson
- D. Benners
Correct Answer: C
Rationale: The theory of Nursing as Caring was developed by Dr. Jean Watson, a renowned nurse theorist and professor. Watson's Theory of Human Caring focuses on the importance of the nurse-patient relationship, emphasizing the significance of caring in promoting healing and promoting holistic well-being. This theory emphasizes the humanistic aspects of nursing care and highlights the nurse's role in fostering a caring environment that encompasses physical, emotional, social, and spiritual dimensions. Watson's theory emphasizes the importance of empathy, compassion, and authentic presence in nursing practice, making it a valuable framework for guiding nursing care and promoting healing outcomes.