Nokea
What is a critical component of the evaluation phase in the nursing process?
- A. Determine if client outcomes have been achieved
- B. Revise the client’s health history
- C. Establish priorities for care
- D. Formulate new nursing diagnoses
Correct Answer: A
Rationale: Step 1: Evaluation phase assesses if client outcomes have been achieved.
Step 2: Determines effectiveness of nursing interventions.
Step 3: Validates if goals are met or adjustments are needed.
Step 4: Reflects on the success of the care plan.
Step 5: Choice A is correct as it directly relates to evaluating the effectiveness of nursing care.
Summary:
- Choice B is incorrect as revising health history is part of assessment.
- Choice C is incorrect as establishing priorities is part of the planning phase.
- Choice D is incorrect as formulating new nursing diagnoses is part of the diagnosis phase.
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The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
- A. 30% to 35% carbohydrate, 40% fat, and 25% to 30% protein
- B. 40% to 45% carbohydrate, 40% fat, and 15% to 20% protein
- C. 50% to 55% carbohydrate, 35% fat, and 10% to 15% protein
- D. 55% to 60% carbohydrate, 30% fat and 10% to 15% protein
Correct Answer: C
Rationale: The correct answer is C (50% to 55% carbohydrate, 35% fat, and 10% to 15% protein) for managing diabetes. Carbohydrates impact blood sugar levels the most, so a moderate intake is crucial. The fat percentage is lower to reduce the risk of cardiovascular issues, common in diabetics. Protein intake is moderate for muscle maintenance. Choice A has higher fat and lower carbohydrate, not ideal for diabetes. Choice B has too high carbohydrate, which can spike blood sugar. Choice D has the highest carbohydrate percentage, which is not recommended for diabetes management.
A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?
- A. The patient rates the pain at 3 to 4 on a 0 to 10 scale
- B. The patient has full ROM of the upper extremities
- C. The patient demonstrates correct self-administration of analgesics
- D. The patient is able to ambulate 25 feet without pain
Correct Answer: D
Rationale: The correct answer is D: The patient is able to ambulate 25 feet without pain. This outcome indicates successful plan implementation for impaired mobility due to nerve compression. Ambulating without pain shows improved mobility and nerve compression relief. Choices A, B, and C do not directly address mobility improvement. Choice A focuses on pain level, which is important but not a direct measure of mobility. Choice B refers to upper extremities, not the lower extremities affected by lumbar disk herniation. Choice C addresses medication management, not mobility improvement.
Then the drug is stopped. When should treatment resume?
- A. When the WBC falls to 5,000mm3
- B. When lost hair begins to grow back
- C. When the WBC count rises to 50,000/mm3
- D. When the client displays anemia
Correct Answer: A
Rationale: The correct answer is A: When the WBC falls to 5,000mm3. This is because a low WBC count indicates potential bone marrow suppression from the drug. Resuming treatment at this point ensures the bone marrow has recovered enough to handle the drug's effects.
Summary:
- Choice B: Hair regrowth is not a reliable indicator of bone marrow recovery.
- Choice C: A high WBC count suggests potential toxicity, not readiness for treatment.
- Choice D: Anemia is a late sign of bone marrow suppression, not an appropriate indicator to resume treatment.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: B
Rationale: The correct answer is B: Expressive aphasia and paralysis on the left side of the body. In a right-handed person, the left side of the brain controls language (Broca's area) and motor function for the right side of the body. A stroke affecting the left side of the cortex would lead to expressive aphasia (difficulty speaking) due to damage to Broca's area and paralysis on the right side of the body due to motor function impairment. Choices A, C, and D are incorrect because they do not align with the known neurological functions of the brain regions affected by the stroke.
Which of the ff is a reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy?
- A. The adverse effect of mastectomy are immediate
- B. The wound of the surgery is highly contagious and the client should exercise isolation precautions immediately after the procedure
- C. Most clients are not hospitalized long after a mastectomy
- D. The suicidal tendencies in the women undergoing a mastectomy are high
Correct Answer: C
Rationale: Step 1: Most clients are not hospitalized long after a mastectomy - Correct. This is because mastectomy is often performed as an outpatient procedure, and clients are discharged home shortly after surgery.
Step 2: The adverse effects of mastectomy are not immediate - Incorrect. Adverse effects may occur post-surgery, but early discharge is not solely due to immediate adverse effects.
Step 3: The wound of the surgery is not highly contagious - Incorrect. Mastectomy wounds are not contagious, and isolation precautions are not necessary.
Step 4: Suicidal tendencies in women undergoing mastectomy are not high - Incorrect. While emotional support is crucial, early discharge is not primarily due to suicidal tendencies.
Summary: Choice C is correct because mastectomy clients are typically not hospitalized long, making early discharge instructions and home care arrangements necessary. Choices A, B, and D are incorrect as they do not directly relate to the primary reason for early discharge and home care planning.