Nokea
What does a focused assessment primarily address?
- A. Comprehensive physical findings
- B. Specific client issues
- C. Multiple body systems
- D. Long-term wellness goals
Correct Answer: B
Rationale: The correct answer is B: Specific client issues. A focused assessment is a targeted examination that addresses specific client concerns or issues. By focusing on a particular aspect of the client's health, healthcare providers can gather relevant information efficiently and effectively. This approach allows for a more in-depth evaluation of the specific problem at hand, leading to better treatment outcomes.
Choice A (Comprehensive physical findings) is incorrect because a focused assessment does not aim to gather information on all physical findings, but rather on specific issues. Choice C (Multiple body systems) is incorrect because a focused assessment is more narrow in scope and typically focuses on one area or system of the body. Choice D (Long-term wellness goals) is incorrect as a focused assessment is more immediate and targeted towards addressing current issues rather than long-term goals.
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A nurse is caring for a patient who is receiving chemotherapy. The nurse should monitor for signs of which of the following complications?
- A. Anemia.
- B. Hyperkalemia.
- C. Neutropenia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Neutropenia. Chemotherapy can suppress bone marrow function, leading to a decrease in neutrophils (a type of white blood cell), causing neutropenia. This increases the risk of infection. Monitoring for signs of infection is crucial in patients receiving chemotherapy to prevent serious complications. Anemia (A) is a common side effect of chemotherapy but is not directly related to infection risk. Hyperkalemia (B) and hypocalcemia (D) are less likely to be immediate complications of chemotherapy compared to neutropenia.
Critique the following statement made by the nurse: "I know it may be hard, but you should do what the doctor ordered because he/she is the expert in this field.'
- A. This statement is inappropriate because it shows the nurse's bias.
- B. This statement is appropriate because members of the health care team are experts in the area of patient care.
- C. This type of statement creates dependency and inferiority in the patient and is best avoided in an interview situation.
- D. At times, it is necessary to use authority statements when dealing with patients, especially when they are undecided about an issue.
Correct Answer: C
Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making.
The other choices are incorrect because:
A: This choice focuses on bias, which is not the main issue at hand in this scenario.
B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience.
D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.
What is the most appropriate nursing action for a client with suspected peritonitis?
- A. Administer antibiotics
- B. Administer analgesics
- C. Apply an ice pack
- D. Perform a laparotomy
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum often caused by infection. Administering antibiotics is crucial to combat the infection. It is important to treat the underlying cause first before focusing on symptom management. Administering analgesics (B) may provide temporary relief but won't address the infection. Applying an ice pack (C) is not appropriate for peritonitis as it won't treat the infection. Performing a laparotomy (D) is a surgical procedure that may be necessary in severe cases but is not the initial nursing action.
A nurse is caring for a patient with hypertension. The nurse should monitor for which of the following complications?
- A. Heart failure.
- B. Chronic kidney disease.
- C. Stroke.
- D. All of the above.
Correct Answer: D
Rationale: The correct answer is D. Hypertension can lead to various complications affecting the heart, kidneys, and brain. Monitoring for heart failure is crucial due to the increased workload on the heart. Chronic kidney disease is a common complication of hypertension, as the kidneys are sensitive to changes in blood pressure. Stroke is another significant risk due to the potential damage to blood vessels in the brain. Therefore, monitoring for all these complications is essential in managing a patient with hypertension. Other choices are incorrect as they do not encompass all possible complications of hypertension.
What should the nurse monitor when caring for a client receiving anticoagulant therapy?
- A. Monitor platelet count
- B. Monitor INR levels
- C. Monitor bleeding
- D. Monitor renal function
Correct Answer: B
Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications.
Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy.
Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy.
Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.