Nokea
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. Problem statement
- B. Defining characteristics
- C. Etiology of the problem
- D. Outcomes criteria
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem.
Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.
You may also like to solve these questions
A client in the final stages of terminal cancer tells the nurse: “I wish I could be just be allowed to die. I’m tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the best nurse’s best response?
- A. “Would you like to talk to a psychologist about your thoughts and feelings?”
- B. “Would you like to talk to your minister about the significance of death?”
- C. “Would you like to meet with your family and your physician about this matter?”
- D. “I know you are tired of fighting this illness, but death will come in due time.”
Correct Answer: A
Rationale: The correct answer is A: "Would you like to talk to a psychologist about your thoughts and feelings?" This response acknowledges the client's emotional distress and offers professional support. A psychologist can provide counseling and help the client explore their feelings and concerns about end-of-life decisions.
Choice B is incorrect because it assumes the client's spiritual beliefs are the primary concern, neglecting the emotional and psychological aspects. Choice C involves more people in the decision-making process without addressing the client's individual needs. Choice D is dismissive and does not offer any support or explore the client's feelings further.
In summary, choice A is the best response because it prioritizes the client's emotional well-being and offers appropriate support through professional counseling.
Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
- A. Add any needed IV medication in the blood bag within one hour of planned infusion
- B. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion
- C. Prime tubing of blood administration set with 0.9% NS solution, completely, filling filter
- D. Inadequate dietary intake
Correct Answer: C
Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing.
Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval.
Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused.
Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
- A. “My leg hurts so bad. I can’t stand it.”
- B. “Appears anxious and frightened.”
- C. “I am so sick; I am about to throw up.”
- D. “Unable to palpate femoral pulse in left leg.”
Correct Answer: D
Rationale: The correct answer is D because "Unable to palpate femoral pulse in left leg" is an objective finding that can be measured or observed without interpretation or bias. It provides concrete, measurable information about the patient's condition. Choices A, B, and C are subjective data as they rely on the patient's feelings, emotions, and perceptions, which can vary and are open to interpretation. Objective data is crucial in making accurate assessments and decisions in healthcare.
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: B
Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
- A. adenohypohysis.
- B. alpha cells of the pancreas.
- C. beta cells of the pancreas.
- D. parafollicular cells of the thyroid.
Correct Answer: C
Rationale: Rationale:
1. Insulin is a hormone produced by beta cells of the pancreas.
2. Beta cells are responsible for monitoring blood glucose levels and secreting insulin in response to high glucose levels.
3. Insulin helps regulate blood glucose by facilitating glucose uptake into cells.
4. Adenohypophysis secretes other hormones, not insulin.
5. Alpha cells of the pancreas secrete glucagon, not insulin.
6. Parafollicular cells of the thyroid secrete calcitonin, not insulin.
Summary:
Choice C is correct because insulin is indeed secreted from the beta cells of the pancreas. Choices A, B, and D are incorrect as they do not secrete insulin or are related to other hormones.