Nokea
Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?
- A. Self-esteem disturbance
- B. Impaired urinary elimination
- C. Impaired skin integrity
- D. Risk for infection
Correct Answer: D
Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.
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In conducting a cleansing enema, how does the nurse position the client?
- A. Right lateral position
- B. Left lateral position
- C. Right Sim's position
- D. Left Sim's position
Correct Answer: B
Rationale: In preparing a patient for a cleansing enema, the nurse typically positions the patient in the left lateral position. This position allows for the best flow of the solution due to the anatomical configuration of the colon. The right lateral position, right Sim's position, and left Sim's position are not typically used for this procedure. The rationale provided initially is incorrect as it pertains to lung expansion and postural drainage, which are not relevant to a cleansing enema procedure.
What characterizes Obsessive Compulsive Disorder?
- A. Uncontrollable impulse to perform an act or ritual repeatedly
- B. Persistent thoughts and behavior
- C. Recurring unwanted and disturbing thoughts
- D. Pathological persistence of unwilled thoughts
Correct Answer: A
Rationale: Obsessive Compulsive Disorder (OCD) is characterized by the uncontrollable impulse to perform an act or ritual repeatedly (Choice A). This is driven by recurring unwanted and disturbing thoughts (Choice C), but the distinguishing factor is the compulsive behavior, making choice A the most accurate. While choice B can be seen as true, it lacks the specific detail of the compulsive behavior that makes A a better answer. Choice D is not incorrect, but it uses terminology that is less precise and less commonly used to describe OCD, making it a less accurate choice than A. The provided rationale is not relevant to the question.
Why is a pulse oximeter attached to Mr. Dizon's finger?
- A. To determine if the patient's hemoglobin level is low and if he requires a blood transfusion
- B. To check the level of the patient's tissue perfusion
- C. To measure the effectiveness of the patient's anti-hypertensive medications
- D. To detect oxygen saturation of arterial blood before symptoms of hypoxemia develop
Correct Answer: D
Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.
If it is determined that a child is being physically abused by a parent, what would be the most important goal for the nurse to establish with the family?
- A. The child and any siblings will reside in a secure environment
- B. The family will feel at ease in their relationship with the counselor
- C. The family will gain insight into their abusive behavior patterns
- D. The mother will learn to apply verbal discipline with her children
Correct Answer: A
Rationale: The primary objective when dealing with cases of child abuse is to ensure the safety of the child and any siblings. This means creating a secure environment free from harm, which is why choice 'A' is the correct answer. While choices 'B', 'C', and 'D' might be subsequent steps in a comprehensive plan to deal with the situation, they are not the immediate priority. Understanding abusive behavioral patterns or improving the relationship with the counselor will not directly lead to the child's safety. Likewise, teaching the mother to apply verbal discipline doesn't guarantee the child's safety if the abusive behavior continues. Therefore, these options are not the most important initial goal.
What is the fundamental difference between nursing diagnoses and collaborative problems?
- A. Collaborative problems are managed by nurses using physician-prescribed interventions.
- B. Collaborative problems can be addressed by independent nursing interventions.
- C. Physician-prescribed interventions are incorporated into nursing diagnoses.
- D. Nursing diagnoses include physiologic complications that nurses monitor to detect status changes.
Correct Answer: B
Rationale: The correct answer is B, as collaborative problems necessitate the collective expertise and skills of numerous healthcare professionals, including nurses. These problems can be dealt with through independent nursing interventions in cooperation with other team members. Option A is incorrect because collaborative problems aren't strictly managed with physician-prescribed interventions. Option C is incorrect because nursing diagnoses aim at identifying and treating actual or potential health issues, rather than merely integrating physician-prescribed interventions. Option D is incorrect because nursing diagnoses aim at identifying patient issues, not solely physiologic complications, and guide the necessary nursing care, not just monitor for changes.