Nokea
What is the rationale for giving Mr. Franco frequent mouth care?
- A. He will be thirsty considering that he is doesn’t drink enough fluids
- B. To remove dried blood when tongue is bitten during a seizure
- C. The tactile stimulation during mouth care will hasten return to consciousness
- D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
Correct Answer: B
Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco is important to remove dried blood when the tongue is bitten during a seizure. This is crucial for preventing infection and promoting oral hygiene. Choices A, C, and D are incorrect because the primary reason for mouth care in this case is to address the physical consequences of a seizure, such as tongue biting and potential injury, rather than thirst, tactile stimulation, or prevention of oral mucosal issues related to mouth breathing in a comatose patient.
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A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: C
Rationale: The correct answer is C - Observing closely for signs of respiratory distress. In encephalitis, there is a risk of respiratory compromise due to brain inflammation affecting the respiratory center. Monitoring for signs of respiratory distress is critical to intervene promptly if breathing becomes compromised.
A - Measuring fluid intake and output is important but not as critical as monitoring respiratory distress in encephalitis.
B - Evaluating ventilation capacity and lung sounds is important, but close observation for respiratory distress takes precedence for immediate intervention.
D - Administering an indwelling urethral catheter is not directly related to the client's immediate critical needs in encephalitis.
Which of the ff is the main reason why older clients with AIDS need more care than their younger counterparts?
- A. Because the older clients lack balanced diet and activity
- B. Because older clients lack knowledge about disorders
- C. Because older clients have a faster progression of disease
- D. Because older clients do not generally adhere to a therapy
Correct Answer: C
Rationale: The correct answer is C because older clients with AIDS have a faster progression of the disease due to age-related changes in the immune system, making them more vulnerable to complications. This results in a greater need for care compared to younger counterparts. Choice A is incorrect as lack of balanced diet and activity does not directly relate to the progression of AIDS. Choice B is incorrect as knowledge about disorders is not the main factor affecting the level of care needed. Choice D is incorrect as adherence to therapy is important but not the main reason older clients need more care.
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
- A. lubricate the walls of the intestinal tract
- B. soften the fecal mass and lubricate the walls of the rectum and colon
- C. reduce bacterial content of the fecal mass
- D. coat the walls of the intestines to prevent irritation by the hardened fecal mass
Correct Answer: B
Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.
Mr. RR is being prepared for surgery. Nursing care would include:
- A. Careful assessment of neurologic signs to establish baseline data for post-operative care
- B. Planning activities for Mr. RR
- C. Administration of an SS enema to prevent post-operative impaction
- D. Explaining to Mr. RR post-operative complications
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Assessment of neurologic signs establishes baseline for post-op care.
2. Helps detect any changes post-surgery.
3. Enables prompt intervention if any issues arise.
4. Planning activities (B) is not a priority pre-surgery.
5. Enema (C) may not be necessary for all surgeries.
6. Explaining complications (D) is important but not a primary pre-op nursing care.