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Which goal is most appropriate for the collaborative problem of wound infection?
- A. The patient will not exhibit further signs of infection.
- B. Maintain the patient’s fluid intake at 1000 mL/8 hour.
- C. The patient will have a temperature of 98.6F within 2 days.
- D. Monitor the patient to detect therapeutic response to antibiotic therapy.
Correct Answer: A
Rationale: The most appropriate goal for the collaborative problem of wound infection is "The patient will not exhibit further signs of infection." This goal directly addresses the issue of controlling and resolving the infection within the wound, leading to the overall improvement in the patient's condition. By ensuring that the patient does not exhibit further signs of infection, healthcare providers can monitor the effectiveness of treatment interventions and prevent any complications that may arise from the infection spreading or worsening. In contrast, options B, C, and D are not directly related to addressing the wound infection itself, making them less appropriate goals for this specific problem.
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The nurse is formulating a nursing care plan for a postpartum patient. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply.)
- A. Using a standardized postpartum care plan
- B. Determining priorities for each diagnosis written
- C. Writing interventions from a nursing diagnosis book
- D. Reflecting and suspending judgment when writing the care plan
Correct Answer: B
Rationale: B. Determining priorities for each diagnosis written: Prioritizing nursing diagnoses based on the patient's needs and condition requires critical thinking skills. The nurse must be able to identify the most urgent issues to address first in the care plan.
A 48-year-old female patient presents to the OB/GYN clinic for her annual examination. She states that she has had the following symptoms: mood swings, irregular menstrual cycles, forgetfulness, food cravings, and a decrease in libido. Which of the following does the nurse suspect the patient is experiencing?
- A. Menopause
- B. Perimenopause
- C. Postmenopause
- D. Pregnancy
Correct Answer: B
Rationale: Perimenopause is the transitional period leading to menopause that usually begins in a woman's 40s but can start earlier. During this phase, women may experience symptoms such as mood swings, irregular menstrual cycles, forgetfulness, food cravings, and a decrease in libido, as described by the patient in this case. These symptoms are caused by hormonal fluctuations as the ovaries start to produce less estrogen in preparation for menopause. Menopause occurs when a woman has not had a menstrual period for 12 consecutive months. Postmenopause, on the other hand, refers to the stage after menopause, where menopausal symptoms have generally subsided. The symptoms described by the patient are more indicative of the perimenopausal stage rather than pregnancy, as they are typical signs of hormonal changes associated with the menopausal transition.
The nurse is providing care to a 72-year-old female patient. While providing care, the nurse instructs the patient to slowly rise from a sitting or prone position. What is the pathophysiological reason for this instruction?
- A. The patient is at higher risk for fractures due to postmenopausal osteoporosis.
- B. The patient is at higher risk for hypotension due to decreased baroreceptor sensitivity.
- C. The patient is at higher risk for falls due to decreased muscle strength and balance
- D. The patient is at higher risk for adverse drug reactions due to decreased hepatic function
Correct Answer: B
Rationale: As people age, their baroreceptor sensitivity decreases, making them more prone to orthostatic hypotension, especially when changing positions quickly. Orthostatic hypotension is a significant concern in the elderly population as it can lead to falls and injuries. By instructing the patient to rise slowly from a sitting or prone position, the nurse is helping to prevent a rapid drop in blood pressure that can occur with sudden position changes. This precaution is particularly important in elderly patients to minimize the risk of falls and subsequent injuries.
The nurse is planning a teaching session for staff on ethical theories. Which situation best reflects the Deontologic theory?
- A. Approving a physician-assisted suicide
- B. Supporting the transplantation of fetal tissue and organs
- C. Using experimental medications for the treatment of AIDS
- D. Initiating resuscitative measures on a 90-year-old patient with terminal cancer
Correct Answer: D
Rationale: Deontologic theory, also known as deontological ethics, focuses on the duty to follow moral rules and obligations regardless of the consequences. In this scenario, initiating resuscitative measures on a 90-year-old patient with terminal cancer reflects a commitment to upholding the duty to provide care and uphold the sanctity of life. Despite the patient's poor prognosis, the nurse is ethically bound to provide care according to established principles and guidelines, emphasizing duty over outcome. This aligns with the Deontologic theory's emphasis on following moral rules and obligations without consideration of the consequences.
The nurse is formulating a nursing care plan for a postpartum patient. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply.)
- A. Using a standardized postpartum care plan
- B. Determining priorities for each diagnosis written
- C. Writing interventions from a nursing diagnosis book
- D. Reflecting and suspending judgment when writing the care plan
Correct Answer: B
Rationale: B. Determining priorities for each diagnosis written: Prioritizing nursing diagnoses based on the patient's needs and condition requires critical thinking skills. The nurse must be able to identify the most urgent issues to address first in the care plan.