What common problem is related to outcome identification and planning?
- A. Failing to involve the client in the planning process
- B. Collecting sufficient data to establish a database
- C. Stating specific and measurable outcomes based on nursing diagnoses
- D. Writing nursing orders that are clear and resolve the problem
Correct Answer: A
Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting.
Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.
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Which of the following would the nurse use to document a finding that the patient’s ear is draining?
- A. Otorrhea
- B. Otalgia
- C. Ototoxic
- D. Tinnitus
Correct Answer: A
Rationale: The correct answer is A: Otorrhea. Otorrhea refers to the discharge of fluid from the ear, indicating an abnormal finding of ear drainage. This term specifically describes the symptom of ear drainage, making it the most appropriate choice for documenting this finding. Otalgia (choice B) refers to ear pain, ototoxic (choice C) refers to substances that are harmful to the ear, and tinnitus (choice D) refers to ringing in the ears, none of which accurately describe ear drainage. Therefore, the correct choice is A as it specifically addresses the symptom of ear drainage.
Which drug class is used to reduce symptoms of muscle weakness from myasthenia gravis?
- A. Anticholinesterase drugs
- B. Adrenergic drugs
- C. Anticholinergic drugs
- D. Beta-blocker drugs
Correct Answer: A
Rationale: The correct answer is A: Anticholinesterase drugs. These drugs increase acetylcholine levels at neuromuscular junctions, helping improve muscle strength in myasthenia gravis. Adrenergic drugs (B) and beta-blocker drugs (D) are not typically used to treat muscle weakness in myasthenia gravis. Anticholinergic drugs (C) can worsen symptoms by blocking acetylcholine receptors, making them an inappropriate choice for this condition.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: The correct answer is D - Patency of airway and adequacy of respiration. This is the most important assessment during the acute stage of an unconscious patient like Mr. Franco because maintaining a clear airway and ensuring proper breathing are crucial for sustaining life. Without a patent airway and adequate respiration, the patient's oxygen supply could be compromised, leading to serious complications such as hypoxia or respiratory failure. Monitoring the airway and respiratory status takes precedence over other assessments in this scenario.
A: Level of awareness and response to pain - While important, assessing level of awareness and response to pain is secondary to ensuring a patent airway and adequate respiration in an unconscious patient.
B: Papillary reflexes and response to sensory stimuli - While these assessments provide valuable information about neurological function, they are not as critical as maintaining a clear airway and proper breathing in an unconscious patient.
C: Coherence and sense of hearing - Coherence and sense of hearing are not as vital as
A patient teaching plan should include which of the ff. lifestyle modifications to help control hypertension?
- A. Regular aerobic exercise
- B. Three alcoholic beverages per day
- C. Low-tar cigarettes
- D. Daily multivitamin supplements
Correct Answer: A
Rationale: Step 1: Regular aerobic exercise helps lower blood pressure by improving heart health and circulation.
Step 2: Exercise reduces stress and promotes weight loss, factors that contribute to hypertension control.
Step 3: Alcohol consumption can raise blood pressure and should be limited or avoided.
Step 4: Smoking and using low-tar cigarettes can still raise blood pressure and have other negative health effects.
Step 5: Daily multivitamin supplements do not directly impact blood pressure control.
There seems to be a positive correlation between type 2 diabetes mellitus and:
- A. Hypotension
- B. Obesity
- C. Kidney dysfunction
- D. Sex
Correct Answer: B
Rationale: The correct answer is B: Obesity. Obesity is a well-established risk factor for developing type 2 diabetes mellitus due to the increased resistance of body cells to insulin. This leads to elevated blood sugar levels. Hypotension (A) is low blood pressure and is not typically associated with type 2 diabetes. Kidney dysfunction (C) is a complication of diabetes but not a direct correlation. Sex (D) does not have a direct link to the development of type 2 diabetes. Therefore, the most likely correlation is with obesity due to its impact on insulin resistance.