Nokea
The patient is having difficulty coping with her new diagnosis of lymphoma. Which response by the nurse is most helpful?
- A. “Don’t worry. You’ll be okay.”
- B. “The treatments you are receiving will make you feel better very soon.”
- C. “Who do you usually go to when you have a problem?”
- D. “Have you made end-of-life decisions?”
Correct Answer: C
Rationale: The correct answer is C because it helps the patient explore her support system. By asking who she usually goes to when facing problems, the nurse encourages the patient to identify her sources of emotional support, which can help her cope with the new diagnosis. This response acknowledges the patient's need for support and fosters a therapeutic relationship.
Explanation for incorrect choices:
A: "Don't worry. You'll be okay." - This response dismisses the patient's feelings and offers false reassurance, which may not address her emotional needs.
B: "The treatments you are receiving will make you feel better very soon." - While this statement provides information about treatment, it does not directly address the patient's difficulty in coping with the diagnosis.
D: "Have you made end-of-life decisions?" - This response may be premature and could unnecessarily increase the patient's anxiety about her prognosis.
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The adrenal cortex is responsible for producing which substances?
- A. Glucocortocoids and androgens
- B. Mineralocortiroids and
- C. Catecholamines and epinephrine catecholamines
- D. Norepinephine and epinephrine
Correct Answer: A
Rationale: The correct answer is A: Glucocorticoids and androgens. The adrenal cortex is divided into three layers, with the outer layer responsible for producing mineralocorticoids like aldosterone, the middle layer producing glucocorticoids like cortisol, and the inner layer producing androgens. Glucocorticoids are essential for regulating metabolism and immune response, while androgens are male sex hormones. Choices B, C, and D are incorrect because mineralocorticoids, catecholamines, norepinephrine, and epinephrine are produced by different parts of the adrenal gland, not specifically by the adrenal cortex.
A nurse has been caring for a client with chronic obstructive pulmonary disease (COPD). What should the nurse focus on during the evaluation phase?
- A. Documenting all interventions performed
- B. Reviewing the client’s progress toward meeting goals
- C. Delegating further care to another healthcare professional
- D. Ensuring compliance with all physician orders
Correct Answer: B
Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan.
A: Documenting interventions is important but not the primary focus during the evaluation phase.
C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan.
D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
- A. Ask the nursing assistive personnel if the wound looks better.
- B. Document the progress of wound healing as “better” in the chart.
- C. Measure the wound and observe for redness, swelling, or drainage.
- D. Leave the dressing off the wound for easier access and more frequent assessments.
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications.
- Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately.
- Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status.
- Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
The nurse should include in the patient’s teaching plan that if the patient does not take the vitamin B12, which one of the following will develop?
- A. Iron deficiency anemia
- B. Sickle cell anemia
- C. Pernicious anemia
- D. Acquired haemolytic anemia
Correct Answer: C
Rationale: The correct answer is C: Pernicious anemia. Vitamin B12 is essential for the production of red blood cells, and its deficiency can lead to pernicious anemia, characterized by decreased red blood cell production. Without adequate vitamin B12, the body cannot properly utilize iron, leading to anemia. Iron deficiency anemia (choice A) is a result of insufficient iron levels, not vitamin B12 deficiency. Sickle cell anemia (choice B) is a genetic disorder affecting hemoglobin, not related to vitamin B12 deficiency. Acquired haemolytic anemia (choice D) is caused by the premature destruction of red blood cells, not by vitamin B12 deficiency.
Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson’s or Huntington’s diseases, or even epilepsy?
- A. Because clients suffer from depression, anxiety, and inability to perform basic self care
- B. Because clients become paralytic throughout the body
- C. Because the clients bone become weak, brittle, and painful to even move
- D. Because clients generally become very aggressive and violent with other people CARING FOR CLIENTS WITH NEUROLOGIC DEFICITS
Correct Answer: A
Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks.
Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.