Nokea
To promote drainage and reduce pressure from fluid, Nurse Selma nursing intervention is to have the child assume any of the following positions, EXCEPT _____.
- A. tilt head to side if sitting up.
- B. Lie on the affected area
- C. put the pillows behind the head
- D. lie on the non-affected ear.
Correct Answer: B
Rationale: The correct answer is B: Lie on the affected area. This position would hinder drainage and increase pressure on the affected area. A: Tilt head to the side if sitting up, is correct as it promotes drainage. C: Putting pillows behind the head can also aid drainage. D: Lying on the non-affected ear can help reduce pressure on the affected side.
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A patient expresses concerns about the financial implications of their treatment plan. What is the nurse's best response?
- A. Dismiss the patient's concerns and assure them that the treatment plan is necessary.
- B. Provide the patient with information about financial assistance programs and resources.
- C. Ignore the patient's concerns and proceed with implementing the treatment plan.
- D. Tell the patient that financial concerns should not affect their decision-making.
Correct Answer: B
Rationale: The correct answer is B because the nurse's role is to address the holistic needs of the patient, including financial concerns. Providing information about financial assistance programs and resources shows empathy and supports the patient in making informed decisions.
Choice A is incorrect because dismissing the patient's concerns can lead to a breakdown in trust and communication. Choice C is incorrect as ignoring the patient's concerns is not addressing the patient's needs. Choice D is incorrect because financial concerns are valid and should be considered in decision-making.
You should check the patient for suspect disturbed thought processes related to depressed metabolism and altered cardiovascular and respiratory status. What is the rationale for orienting the patient to time, place, date, and events?
- A. Shows improved cognitive functioning
- B. Provides reality orientation to patient
- C. Permits evaluation of effectiveness of treatment
- D. Let the patient identify the time, place, date, and events correctly
Correct Answer: B
Rationale: The correct answer is B: Provides reality orientation to patient. Orienting the patient to time, place, date, and events helps them stay connected to reality and improves their awareness of their surroundings. This is crucial in assessing their cognitive functioning and ensuring they are grounded in the present moment. By providing reality orientation, healthcare providers can better understand the patient's current mental state and address any potential confusion or disorientation. This approach aids in establishing a therapeutic environment and enhances the patient's overall well-being. Choices A, C, and D do not capture the essence of reality orientation and its significance in maintaining the patient's mental clarity and connection to the present moment.
The physician prescribes decongestant intranasal spray. The nurse instructs the client on the proper use of the spray. Which of the following procedures is the CORRECT method?
- A. Finish instillation of spray into one nostril before spraying into the other nostril
- B. Inhale quickly to prevent irritation off the mucous membranes
- C. Blow the nose after spraying to prevent medications from entering the throat
- D. Tilt the head slightly forward and angle the bottle toward the side of the nostril
Correct Answer: D
Rationale: The correct answer is D: Tilt the head slightly forward and angle the bottle toward the side of the nostril. This method allows for proper administration of the spray into the nasal passage, ensuring effective delivery of the medication. Tilted head helps direct the spray towards the nasal cavity without causing discomfort or leakage. It also helps prevent the medication from dripping down the back of the throat.
Choices A, B, and C are incorrect:
A: Finishing instillation in one nostril before moving to the other can lead to uneven distribution of medication and reduced effectiveness.
B: Inhaling quickly may cause irritation and discomfort to the mucous membranes due to the forceful intake of the spray.
C: Blowing the nose after spraying can expel the medication before it has a chance to be absorbed, decreasing its efficacy.
The nurse specialist explains that chemotherapyis extremely toxic to the bone marrow and the patient may develop thrombocytopenia. What is the priority goal of the nurse? To take precautions to control _______.
- A. Bleeding
- B. Infection
- C. Hypotension
- D. diarrhea
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Chemotherapy can lead to low platelet counts (thrombocytopenia), increasing the risk of bleeding. The priority goal of the nurse is to prevent bleeding by taking precautions such as avoiding invasive procedures, using soft toothbrushes, and monitoring for signs of bleeding. Infection (B) is important but not the priority as bleeding can be life-threatening. Hypotension (C) is not directly related to thrombocytopenia. Diarrhea (D) is a potential side effect of chemotherapy but is not the priority when considering thrombocytopenia.
To begin your discussion, you explain to her that the endocrine glands include, which of the following?
- A. Pituitary, thyroid, parathyroid, adrenals, pancreaticislets, and hypothalamus
- B. Pituitary, thyroid, parathyroid, pancreatic islets, ovaries, and testes
- C. Pituitary, thyroid, parathyroid, adrenals and pancreatic islets
- D. Pituitary, thyroid, parathyroid, adrenals, pancreatic islets, ovaries and testes
Correct Answer: A
Rationale: The correct answer is A because it includes all the major endocrine glands: pituitary, thyroid, parathyroid, adrenals, pancreatic islets, and hypothalamus. The pituitary gland is known as the "master gland" as it controls other endocrine glands. The thyroid gland regulates metabolism, while the parathyroid glands regulate calcium levels. The adrenal glands produce hormones involved in stress response. Pancreatic islets produce insulin and glucagon. The hypothalamus plays a key role in hormone regulation.
Choice B is incorrect because it includes ovaries and testes, which are not endocrine glands. Choice C is incorrect because it omits the hypothalamus. Choice D is incorrect because it includes ovaries and testes which are not endocrine glands.