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When conducting a nursing history on the Health Perception, Health Management pattern of functioning what is the APPROPRIATE question to be asked pre-operatively?
- A. Do you experience your wound to heal quickly?
- B. Do you have shortness of breath when exercising?
- C. Are you aware of risk factors for your disease?
- D. Have you experience weight changes in the past?
Correct Answer: C
Rationale: When conducting a nursing history on the Health Perception, Health Management pattern of functioning pre-operatively, an appropriate question to ask would be "Are you aware of risk factors for your disease?" This question helps assess the individual's level of awareness and understanding of their health condition and the factors that may impact it. Understanding the patient's knowledge of their risk factors can help guide interventions and education before surgery to optimize their health outcomes. Asking about perceived wound healing, shortness of breath, or weight changes may not be directly related to the patient's awareness of their disease risk factors in the pre-operative setting.
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A patient with a history of heart failure is prescribed spironolactone. Which electrolyte imbalance is the patient at risk for developing with spironolactone therapy?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic commonly used in the management of heart failure. One of the significant side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the bloodstream. Spironolactone works by blocking the action of aldosterone, a hormone that regulates potassium and sodium balance in the body. By inhibiting aldosterone, spironolactone reduces potassium excretion in the urine, leading to potential accumulation of potassium in the body.
A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?
- A. Administering naloxone prophylactically
- B. Monitoring oxygen saturation with pulse oximetry
- C. Encouraging deep breathing exercises
- D. Administering bronchodilators as needed
Correct Answer: B
Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.
Context of a verbal communication is the:
- A. Use of understandable
- B. Use of clear sentences
- C. Use of literal words
- D. Environment where communication occurs
Correct Answer: D
Rationale: The context of a verbal communication is the environment or situation in which the communication takes place. It includes factors such as the physical setting, the social or cultural background, the relationship between the speaker and the listener, and any other relevant conditions that may impact the understanding of the message. Understanding the context is essential for effective communication as it helps to interpret the meaning behind the words spoken and ensures that the message is appropriately received.
When the patient was informed about induction, she asks Nurse Aurora what it is all about. which of the following statement by the nurse is correct? Induction is a
- A. local anesthesia used for blocking pain during episiotomy
- B. deliberate initiation of uterine contractions that stimulates labor
- C. medication injected into the subarachnoid space and has a rapid onset of action
- D. procedure per formed by artificial rupture of the membranes
Correct Answer: B
Rationale: Induction is the deliberate initiation of uterine contractions that stimulates labor. It is usually initiated when natural labor is not progressing or is overdue. This process can involve the use of medications or other methods to help the uterus contract and initiate labor. Option B accurately describes induction, making it the correct answer in this case.
A patient presents with a sudden onset of severe vertigo, nausea, vomiting, and nystagmus. The patient reports a recent upper respiratory tract infection. Which of the following conditions is most likely responsible for this presentation?
- A. Vestibular neuritis
- B. Benign paroxysmal positional vertigo (BPPV)
- C. Ménière's disease
- D. Acoustic neuroma
Correct Answer: A
Rationale: The patient's sudden onset of severe vertigo, nausea, vomiting, and nystagmus following a recent upper respiratory tract infection is consistent with vestibular neuritis. Vestibular neuritis is characterized by acute onset vertigo, often severe, which is typically associated with nausea, vomiting, and nystagmus. The condition is thought to be caused by inflammation of the vestibular nerve, often viral in nature, which can occur following an upper respiratory tract infection. This inflammation leads to dysfunction of the vestibular system in the inner ear, resulting in the symptoms described. Benign paroxysmal positional vertigo (BPPV), characterized by brief episodes of vertigo triggered by specific head movements, is less likely in this case given the sudden onset of symptoms not triggered by head movements. Meniere's disease is characterized by recurrent episodes of vertigo accompanied by hearing loss, tinnitus, and a feeling of fullness