Nokea
Which finding should the nurse expect?
- A. Move quickly from one idea to the next
- B. Feelings of hopelessness or worthlessness
- C. Decreased energy and fatigue
- D. Difficulty concentrating or making decisions
- E. Changes in appetite, either increased or decreased
Correct Answer: B
Rationale: The correct answer is B: Feelings of hopelessness or worthlessness. This is a key symptom of depression and is often present in individuals experiencing a depressive episode. It is important for the nurse to recognize this as it can indicate a serious mental health issue that requires intervention. Choices A, C, D, and E are also common symptoms of depression, but they are not as specific to the core of the condition as feelings of hopelessness or worthlessness. Moving quickly from one idea to the next (A) may suggest mania or hypomania rather than depression. Decreased energy and fatigue (C), difficulty concentrating or making decisions (D), and changes in appetite (E) are also common in depression, but they are not as indicative of the deep emotional distress associated with feelings of hopelessness or worthlessness.
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Which of the following information should the nurse include?
- A. Return in two weeks for a follow up MRI - MRI should be avoided
- B. Expect to have a rapid pulse rate for the first few weeks?
- C. Resume tub baths and swimming after 24hr
- D. Wear loose fitting clothing
Correct Answer: D
Rationale: The correct answer, D, "Wear loose fitting clothing," is important post-surgery to prevent constriction on the surgical site and promote healing. Tight clothing can lead to increased pain and delayed recovery. Choice A is incorrect as MRI should be avoided post-surgery due to potential interference with healing. Choice B is incorrect as a rapid pulse rate is not a typical expectation post-surgery. Choice C is incorrect as tub baths and swimming should be avoided to prevent infection.
Which action should the nurse include in the plan?
- A. Offer the client three large meals each day
- B. Provide small, frequent meals to reduce fatigue and improve intake.
- C. Encourage the client to drink fluids immediately before or after meals to prevent early satiety.
- D. Offer high-calorie, nutrient-dense foods to support weight maintenance.
- E. Monitor the client's weight regularly to assess nutritional status.
Correct Answer: B
Rationale: The correct answer is B: Provide small, frequent meals to reduce fatigue and improve intake. This option is the most appropriate because small, frequent meals can help prevent fatigue and improve nutrient intake by ensuring a steady supply of energy throughout the day. Offering three large meals (option A) may overwhelm the client and lead to fatigue. Encouraging fluid intake before or after meals (option C) may cause early satiety and reduce food intake. Offering high-calorie, nutrient-dense foods (option D) can be beneficial, but the frequency of meals is more crucial in this scenario. Monitoring weight (option E) is important but does not directly address the issue of fatigue and intake.
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A,B,F
Rationale: The correct interventions are A, B, and F.
A: Increasing oxygen flow rate to 4 L/min ensures adequate oxygenation for the client.
B: Assessing breath sounds helps monitor respiratory status and detect any abnormalities.
F: Instructing the client to perform diaphragmatic breathing promotes effective use of respiratory muscles.
Incorrect choices:
C: Chest percussion and vibration are not typically indicated for all clients and may not be appropriate in this case.
D: Placing the client in a supine position can worsen respiratory function, especially in certain conditions.
E: Restricting fluid intake may not be necessary unless specifically ordered by a healthcare provider and could potentially lead to dehydration.
Which of the following findings should the nurse expect?
- A. Reduce right sided breath sounds
- B. Inter coastal retractions
- C. High pitched strider
- D. Paradoxical chest movement
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. This finding suggests a potential pneumothorax on the right side, where air leaks into the pleural space causing lung collapse and decreased breath sounds. Intercostal retractions (B) indicate increased work of breathing, likely due to respiratory distress but not specific to a pneumothorax. High-pitched stridor (C) is a sign of upper airway obstruction, not typically seen with pneumothorax. Paradoxical chest movement (D) is seen in flail chest, not characteristic of pneumothorax.
which of the following findings should the nurse recognize as an expected finding?
- A. The anterior fontanel is open
- B. The posterior fontanel is open
- C. The anterior fontanel is sunken
- D. The anterior fontanel is bulging
Correct Answer: A
Rationale: The correct answer is A: The anterior fontanel is open. This is an expected finding in infants as the anterior fontanel typically remains open until around 18-24 months of age, allowing for the growth and expansion of the skull bones. It is a normal part of development and closure indicates maturation. The posterior fontanel closes earlier than the anterior fontanel, so option B is incorrect. Option C, sunken anterior fontanel, indicates dehydration, while option D, bulging anterior fontanel, is a sign of increased intracranial pressure, both of which are abnormal findings.