Nokea
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
- A. Acute pain related to biologic and chemical factors
- B. Anxiety related to change in or threat to health status
- C. Hopelessness related to deteriorating physiological condition
- D. Risk for side effects related to medical therapy
Correct Answer: A
Rationale: The priority nursing diagnosis for a patient experiencing a migraine headache is 'Acute pain related to biologic and chemical factors.' Migraine headaches are characterized by severe throbbing pain, often accompanied by sensitivity to light and sound. Addressing the acute pain is crucial to improve the patient's comfort and quality of life. Choices B, C, and D are not the priority nursing diagnoses for a patient with a migraine headache. Anxiety, hopelessness, and risk for side effects may not be as urgent as managing the acute pain associated with a migraine.
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Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?
- A. Increase activity level.
- B. Maintain adequate nutrition
- C. Establish a stable environment
- D. Identify sources of hepatitis exposure
Correct Answer: B
Rationale: The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.
After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?
- A. Administer hepatitis B vaccine.
- B. Test for antibodies to hepatitis B.
- C. Teach about alpha-interferon therapy.
- D. Give hepatitis B immune globulin.
Correct Answer: C
Rationale: In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.
The nurse is caring for a 73-year-old man with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
- A. The patient complains of right upper-quadrant pain upon palpation.
- B. The patient's hands flap back and forth when the arms are extended.
- C. The patient has ascites and a 2-kg weight gain from the previous day.
- D. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
Correct Answer: B
Rationale: The most concerning data obtained by the nurse is the patient's hands flapping back and forth when the arms are extended, indicating asterixis, which is associated with hepatic encephalopathy. This condition can progress to hepatic coma and requires immediate attention. The presence of spider angiomas and right upper-quadrant abdominal pain are common findings in cirrhosis and do not warrant urgent intervention. Although ascites and weight gain suggest the need for treatment, they are not as alarming as the neurologic manifestations seen in hepatic encephalopathy.
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening.
- B. Perform tests for sexually transmitted diseases.
- C. Discuss her high risk for cervical cancer.
- D. Refer the client to a family planning clinic.
Correct Answer: A
Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV. Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes. Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?
- A. Ask the patient to extend both arms forward.
- B. Request that the patient walk with eyes closed.
- C. Ask the patient to perform the Valsalva maneuver.
- D. Observe the patient's breathing pattern.
Correct Answer: B
Rationale: To evaluate treatment effectiveness for a patient with hepatic encephalopathy, requesting the patient to walk with eyes closed is crucial. This test assesses the patient's balance, gait, and coordination, which can be impaired in hepatic encephalopathy due to altered mental status and brain function. Walking with eyes closed challenges the patient's sensory input and proprioception, providing valuable information on improvement or deterioration in neurological function. Asking the patient to extend both arms forward is used to check for asterixis, a sign often seen in hepatic encephalopathy, but it is not specific for evaluating treatment effectiveness. Performing the Valsalva maneuver is unrelated to assessing hepatic encephalopathy and is more commonly used in cardiac evaluations. Observing the patient's breathing pattern may be important in other conditions but is not directly relevant to evaluating treatment effectiveness for hepatic encephalopathy.