Nokea
What is the M0ST APPROPRIATE nursing diagnosis for this patient?
- A. Self-care deficit related to neuromuscular impairment.
- B. Alteration in nutritional status related to possible choking .
- C. Alteration in nutritional status related to anorexia.
- D. Alteration in urinary elimination related to sensory motor impairment.
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.
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A patient presents with knee pain and swelling following a fall onto a flexed knee. Physical examination reveals a palpable effusion and tenderness along the joint line. McMurray's test elicits pain and clicking with passive knee flexion and internal rotation. Which condition is most likely?
- A. Patellar tendinitis
- B. Medial meniscus tear
- C. Lateral collateral ligament (LCL) sprain
- D. uadriceps tendon rupture
Correct Answer: B
Rationale: The presentation of knee pain and swelling following a fall onto a flexed knee, along with a palpable effusion and tenderness along the joint line, is highly suggestive of a meniscus injury. The McMurray's test specifically evaluates for meniscal tears. In this case, the presence of pain and clicking with passive knee flexion and internal rotation indicates a medial meniscus tear as the most likely diagnosis. Patellar tendinitis usually presents with anterior knee pain that is worsened by activities such as jumping or running. Lateral collateral ligament (LCL) sprain typically presents with lateral knee pain and instability. Quadriceps tendon rupture would present with significant weakness and inability to fully extend the knee, which is not described in this scenario.
A nurse is preparing to assist with a magnetic resonance imaging (MRI) procedure for a patient. What action should the nurse prioritize to ensure procedural safety?
- A. Screening the patient for contraindications to MRI, such as metal implants or claustrophobia
- B. Administering intravenous sedation to the patient before the procedure
- C. Placing the patient in a supine position with arms at their sides during the MRI scan
- D. Allowing the patient to wear metallic jewelry or accessories during the procedure
Correct Answer: A
Rationale: The nurse should prioritize screening the patient for contraindications to MRI, such as metal implants or claustrophobia, to ensure procedural safety. Metallic objects can be hazardous in an MRI environment as they can be attracted to the magnet, potentially causing harm to the patient or staff. Claustrophobia can also be a significant issue for patients undergoing an MRI scan, and identifying this beforehand allows for appropriate measures to be taken to address the patient's anxiety or discomfort. Prioritizing this screening step helps ensure the safety and well-being of the patient during the MRI procedure.
Mrs. Carpio has an order of Thiazide diuretics for her edema. The following is the entry that you expect to be written in her progress report EXCEPT ______.
- A. Serum electrolyte monitored everyday
- B. Intake and output done every shift
- C. Weight taken before drug is administered
- D. Drug is administered at 8o'clock in the evening
Correct Answer: D
Rationale: The entry you expect to be written in Mrs. Carpio's progress report should include details related to monitoring her response to the Thiazide diuretics and ensuring her safety. Options A, B, and C all focus on these aspects by monitoring serum electrolytes, intake and output, and weight before drug administration, which are important considerations when a patient is on Thiazide diuretics. However, specifying the time of drug administration (8 o'clock in the evening) is not necessary in the progress report entry. The focus should be on the patient's response to the medication and the associated monitoring parameters. Time of administration is more relevant for nursing care plans or medication schedules.
Therapeutic treatment for Mrs. Juan should be directed towards helping her to ______.
- A. learn that her behavior is not serving a realistic purpose
- B. forget her fears by administering antianxiety medications
- C. redirect her energy into activities to help others
- D. understand her behavior is caused by unconscious impulses that she fears
Correct Answer: C
Rationale: Mrs. Juan's therapeutic treatment should focus on redirecting her energy into activities that involve helping others. By engaging in altruistic activities, Mrs. Juan can shift her focus away from her fears and anxieties towards something positive and fulfilling. This approach can help her to find purpose and meaning outside of her own concerns, fostering a sense of well-being and satisfaction. Additionally, helping others can provide Mrs. Juan with a sense of accomplishment and self-worth, ultimately contributing to her overall mental health and emotional resilience.
When caring for patients with hyperbilirubinemia, the nursing care plan should focus on the following, EXCEPT_________.
- A. informing appropriately the significant others
- B. preventing injury
- C. maintaining physiological homeostasis with bilirubin levels increasing
- D. preventing complications.
Correct Answer: C
Rationale: When caring for patients with hyperbilirubinemia, the nursing care plan should focus on informing the significant others, preventing injury, and preventing complications. The primary goal in managing hyperbilirubinemia is to prevent complications associated with high bilirubin levels, such as kernicterus. Therefore, maintaining physiological homeostasis with bilirubin levels increasing would not be appropriate and should not be the focus of the nursing care plan. It is crucial to monitor and manage bilirubin levels to prevent adverse outcomes rather than allowing them to increase.