Nokea
What is the primary purpose of the implementation step in the nursing process?
- A. To establish priorities for the client’s care
- B. To carry out the plan of care
- C. To identify client outcomes
- D. To validate nursing diagnoses
Correct Answer: B
Rationale: The correct answer is B: To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (A) is done during the planning phase, identifying client outcomes (C) is part of the evaluation phase, and validating nursing diagnoses (D) is typically done during the assessment phase, not implementation.
You may also like to solve these questions
The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
- A. hypotension
- B. thick, coarse skin
- C. deposits of adipose tissue in the trunk and dorsocervical area
- D. weight gain in arms and legs
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat.
A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation.
B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation.
D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.
Which of the ff. is the best explanation of emphysema for a newly diagnosed patient?
- A. “You have inflamed bronchioles, which causes a lot of secretions.”
- B. “Your lungs have lost some of their elasticity, and air gets trapped.”
- C. “The blood supply to your lungs is damaged, so you can’t absorb oxygen.”
- D. “You have large dilated sacs of sputum in your lungs.”
Correct Answer: B
Rationale: The correct answer is B because emphysema is characterized by the destruction of the alveoli walls, leading to a loss of elasticity in the lungs. This results in air becoming trapped in the lungs, making it difficult to exhale properly.
Explanation for why the other choices are incorrect:
A: Inflamed bronchioles causing secretions describe bronchitis, not emphysema.
C: Damage to the blood supply isn't a primary feature of emphysema; it's more about lung tissue destruction.
D: Large dilated sacs of sputum in the lungs is not an accurate description of emphysema; it's more related to bronchiectasis.
A client who is HIV positive should have the mouth examined for which oral problem common associated with AIDS?
- A. Halitosis
- B. Creamy white patches
- C. Carious teeth
- D. Swollen lips
Correct Answer: B
Rationale: The correct answer is B: Creamy white patches. These patches are indicative of oral thrush, a common fungal infection seen in individuals with weakened immune systems like those with AIDS. This infection is caused by Candida albicans. It presents as white patches on the tongue, inner cheeks, or roof of the mouth. Halitosis (A) is bad breath, not specific to AIDS. Carious teeth (C) refers to cavities, not directly related to AIDS. Swollen lips (D) can be a symptom of various oral conditions, but not specific to AIDS. In summary, creamy white patches are a characteristic oral problem associated with AIDS due to opportunistic infections like oral thrush.