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Which information indicates a nurse has a good understanding of a goal? It is a statement describing the patient’s accomplishments without a time
- A. restriction.
- B. It is a realistic statement predicting any negative responses to treatments.
- C. It is a broad statement describing a desired change in a patient’s behavior.
- D. It is a measurable change in a patient’s physical state.
Correct Answer: D
Rationale: Step 1: A goal should be measurable to track progress effectively.
Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome.
Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound.
Step 4: Other choices lack the specificity and measurability required for a clear goal.
Step 5: Choice A talks about restriction, which is not directly related to understanding a goal.
Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal.
Step 7: Choice C is vague and lacks the specificity of a measurable outcome.
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Which of the ff is a critical task of a nurse during the uterosigmoidostomy procedure for treating a malignant tumor?
- A. Inspecting for bleeding or cyanosis
- B. Inspecting for symptoms of peritonitis
- C. Assessing the clients allergy to iodine
- D. Checking for signs of electrolyte losses
Correct Answer: A
Rationale: The correct answer is A: Inspecting for bleeding or cyanosis. During uterosigmoidostomy, the nurse's critical task is to monitor for any signs of bleeding or cyanosis, which are indicators of potential complications such as hemorrhage or impaired blood flow. This involves observing the surgical site for any abnormal bleeding and assessing the skin color for signs of inadequate oxygenation. Inspecting for symptoms of peritonitis (B) is not directly related to this surgical procedure. Assessing the client's allergy to iodine (C) is important but not a critical task during the procedure. Checking for signs of electrolyte losses (D) is important but not as critical as monitoring for immediate postoperative complications like bleeding or cyanosis.
A 25-year old with hepatitis may be anicteric and symptomless. In the early part of the hepatic inflammatory disorder, the most likely symptom/sign is:
- A. dark urine
- B. occult blood in stools
- C. ascites
- D. anorexia
Correct Answer: D
Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data are measurable and observable facts. Respirations (C) of 16 per minute is objective data as it is a quantifiable measurement that can be counted and recorded. It is not influenced by personal interpretation or bias. Choices A, B, and D are subjective data as they rely on the patient's feelings, perceptions, or symptoms, which can vary and are open to interpretation. Therefore, choice C is the correct answer as it represents concrete, verifiable information that can be used in the patient's assessment and care planning.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This is the most appropriate nursing diagnosis for a patient with pneumonia and lower lobe infiltrates. The rationale is that pneumonia causes inflammation and fluid accumulation in the alveoli, impairing the exchange of oxygen and carbon dioxide in the lungs. This directly affects gas exchange.
Choice A is incorrect because ineffective breathing pattern is a broad nursing diagnosis that does not specifically address the underlying issue of impaired gas exchange in pneumonia. Choice B is incorrect as the risk of infection related to the chest x-ray procedure is unrelated to the patient's current condition of pneumonia. Choice C is also incorrect as dehydration does not directly correlate with the patient's diagnosis of pneumonia and lower lobe infiltrates.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data are measurable and observable, such as vital signs. Respirations of 16 are a specific numerical measurement that can be quantified. This makes choice C the correct answer as it is factual and quantifiable. Choices A, B, and D are subjective data, as they rely on the patient's feelings or experiences, which are open to interpretation and not measurable. Therefore, the nurse should report choice C as objective data as it provides concrete information for assessment and decision-making.