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Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
- A. weak movement of the patient’s toes
- B. decreased pedal pulses
- C. severe, unrelieved pain
- D. presence of foot pallor
Correct Answer: C
Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.
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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:
1. This step follows setting the agenda to focus on patient's main issues.
2. Allows nurse to gather essential information for effective care.
3. Builds rapport and shows patient-centered approach.
Summary of other choices:
A: Introductions are typically done at the beginning of the interview.
C: Prematurely ending the interview may hinder rapport and information gathering.
D: Administering medications is not the immediate priority after setting the agenda.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. This type of diagnosis focuses on improving the client's well-being and maximizing their health potential. By adding Readiness for enhanced urinary elimination to the care plan, the nurse acknowledges the patient's willingness to learn self-catheterization, which aligns with health promotion. Other choices are incorrect because: A (Risk) implies potential harm, B (Problem focused) focuses on current issues, and D (Collaborative problem) involves multiple healthcare providers working together on a specific problem.
The nurse should include which of the following in preprocedure teaching for a patient scheduled for carotid angiography?
- A. "You will be put to sleep before the needle Is inserted."
- B. "The test will take several hours."
- C. "You may fee! a burning sensation when the dye is injected."
- D. "There will be no complications."
Correct Answer: C
Rationale: The correct answer is C: "You may feel a burning sensation when the dye is injected." This is important to include in preprocedure teaching for carotid angiography because it prepares the patient for a common sensation they may experience during the procedure. Providing this information helps manage expectations and reduce anxiety.
Choice A is incorrect because carotid angiography is typically done with the patient awake. Choice B is incorrect as carotid angiography usually takes around 30-60 minutes. Choice D is incorrect because there can be complications associated with carotid angiography, such as allergic reactions or damage to blood vessels.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis related to enhancing the patient's urinary elimination abilities through self-catheterization, which focuses on promoting the patient's health and well-being. The Readiness for enhanced urinary elimination diagnosis indicates the patient's motivation and readiness to improve their urinary elimination abilities, aligning with the concept of health promotion. This type of diagnosis acknowledges the patient's potential for growth and improvement in their health status.
Incorrect choices:
A: Risk - This choice would be more appropriate if the diagnosis focused on potential complications or adverse events related to the patient's urinary elimination abilities.
B: Problem focused - This choice would be suitable if the diagnosis identified an existing issue or problem with the patient's urinary elimination abilities that needed to be addressed.
D: Collaborative problem - This choice would be relevant if the diagnosis required collaboration between healthcare providers to manage the patient's urinary elimination abilities effectively.
To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
- A. In patients who are unconscious
- B. In patients who show neurologic
- C. To prevent fluid overload symptoms
- D. To prevent dehydration
Correct Answer: C
Rationale: Step 1: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood.
Step 2: Restricting fluid intake helps prevent further dilution of sodium in the blood, aiding in correcting hyponatremia.
Step 3: Administering sodium can lead to rapid correction, risking osmotic demyelination syndrome.
Step 4: Choice C is correct as it aligns with the goal of managing hyponatremia by preventing fluid overload symptoms.
Summary: A, B, and D are incorrect as they do not directly address the primary concern of correcting low sodium levels in hyponatremia.