Nokea
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
- A. Sore throat
- B. Acute pain
- C. Sleep apnea
- D. Heart failure
Correct Answer: B
Rationale: The correct answer is B: Acute pain. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (A) is a symptom, not a diagnosis. Sleep apnea (C) and heart failure (D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.
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A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
- A. Equipment
- B. Safe environment
- C. Confidence
- D. Assistive personnel
Correct Answer: A
Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
- A. neuropathy on her peripheral
- B. nephropathy
- C. carpal tunnel syndrome
- D. macroangiopathy
Correct Answer: A
Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.
The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
- A. Sodium level of 140 mEq/l.
- B. Direct bilirubin level of 2 mg/dl
- C. Prothrombin time of 12 seconds
- D. Platelet count of 400,000/mm3
Correct Answer: B
Rationale: The correct answer is B: Direct bilirubin level of 2 mg/dl. Acetaminophen toxicity can lead to liver damage, causing an increase in bilirubin levels. Direct bilirubin specifically indicates liver function. A: Sodium level is not related to acetaminophen toxicity. C: Prothrombin time is a measure of blood clotting, not indicative of acetaminophen toxicity. D: Platelet count is not affected by acetaminophen toxicity.
The following are warning signs of cancer. Which one is not?
- A. Change In bladder and bowel habits
- B. Weight gain
- C. Indigestion or difficulty in swallowing
- D. Nagging cough or hoarseness
Correct Answer: B
Rationale: The correct answer is B, weight gain, as it is not typically considered a warning sign of cancer. Changes in bladder and bowel habits (A), indigestion or difficulty in swallowing (C), and a nagging cough or hoarseness (D) are commonly associated with various types of cancer. Weight gain is more commonly linked to factors such as diet, exercise, and hormonal imbalances rather than cancer. It is important to be vigilant about the other warning signs and seek medical attention if any of those symptoms persist.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:
- A. Maintain strict isolation
- B. Wear gloves when providing mouth care
- C. Keep the client in a private room, if
- D. Wear a gown when delivering the client’s possible food tray
Correct Answer: B
Rationale: The correct answer is B: Wear gloves when providing mouth care. This is because standard precautions for AIDS include wearing gloves when in contact with bodily fluids, such as saliva during mouth care. Maintaining strict isolation (A) is not necessary as AIDS is not transmitted through casual contact. Keeping the client in a private room (C) is not required unless the client has an airborne infection. Wearing a gown when delivering food tray (D) is not necessary for standard precautions unless there is a risk of contamination with bodily fluids.