Nokea
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.
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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.
A nurse is teaching a patient with chronic hypertension about lifestyle changes. Which of the following is the most appropriate teaching for this patient?
- A. "You should increase your sodium intake to maintain good blood pressure."
- B. "It is important to increase physical activity and reduce stress."
- C. "Take your medications only when your blood pressure increases."
- D. "You should monitor your blood pressure every week."
Correct Answer: B
Rationale: The correct answer is B because increasing physical activity and reducing stress are important lifestyle changes for managing chronic hypertension. Exercise helps lower blood pressure and stress reduction techniques can help control hypertension. Option A is incorrect as reducing sodium intake, not increasing it, is recommended. Option C is incorrect as medications for hypertension should be taken as prescribed, not only when blood pressure increases. Option D is incorrect as monitoring blood pressure should be done regularly, but not necessarily every week.
Which condition is associated with inadequate intake of vitamin C?
- A. Rickets
- B. Marasmus
- C. Kwashiorkor
- D. Scurvy
Correct Answer: D
Rationale: The correct answer is D: Scurvy. Scurvy is caused by a deficiency in vitamin C, which is essential for collagen synthesis. Without enough vitamin C, collagen production is impaired, leading to symptoms like bleeding gums, fatigue, and joint pain.
Incorrect Choices:
A: Rickets is caused by a deficiency in vitamin D, not vitamin C.
B: Marasmus is a severe form of malnutrition due to inadequate intake of calories and protein, not specifically vitamin C.
C: Kwashiorkor is a form of severe acute malnutrition typically caused by inadequate protein intake, not vitamin C deficiency.
In summary, the correct answer is D (Scurvy) because it directly relates to inadequate intake of vitamin C, while the other choices are associated with different nutrient deficiencies.
Which is included only in a comprehensive assessment?
- A. Circulatory assessment
- B. Assessment of the airway
- C. Complete health history
- D. Disability assessment
Correct Answer: C
Rationale: The correct answer is C: Complete health history. In a comprehensive assessment, obtaining a complete health history is essential to gather information about the patient's past and present health conditions, including medical history, family history, social history, and current symptoms. This information helps the healthcare provider understand the patient's overall health status, identify risk factors, and develop an appropriate treatment plan. Assessing the circulatory system (A) and airway (B) are important components of a physical assessment, but they alone do not constitute a comprehensive assessment. Disability assessment (D) focuses on the functional limitations caused by a disability and is not always included in a comprehensive health assessment.
What is the most effective action for a client with suspected sepsis?
- A. Administer antibiotics
- B. Administer fluids
- C. Administer fluids
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.