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Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to collect objective data directly from the patient, which is crucial in establishing a comprehensive patient database. By assessing the patient's physical condition, the nurse can gather vital information such as vital signs, overall health status, and potential areas of concern. Reviewing literature (A) and checking orders for tests (B) may provide additional insights but are not direct data collection methods. Ordering medications (D) is a treatment intervention, not a data collection method.
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When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
- A. Bread
- B. Oranges
- C. Carrots
- D. Strawberries
Correct Answer: D
Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.
After surgery the nurse notes that the patient’s urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this?
- A. The sympathetic nervous system saves fluid in response to stress of surgery.
- B. The sympathetic nervous system diereses fluid in response to stress of surgery.
- C. The parasympathetic nervous system saves fluid in response to stress of surgery.
- D. The parasympathetic nervous system diereses fluid in response to stress of surgery.
Correct Answer: A
Rationale: The correct answer is A: The sympathetic nervous system saves fluid in response to the stress of surgery. The sympathetic nervous system is responsible for the "fight or flight" response, which includes the conservation of fluids during stressful situations. Dark amber and concentrated urine indicates dehydration, which can be a result of the sympathetic nervous system conserving fluids.
B: The sympathetic nervous system does not "diereses" (increase urination) in response to stress.
C: The parasympathetic nervous system is not involved in fluid conservation during stress.
D: The parasympathetic nervous system does not "diereses" fluid in response to stress.
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
- A. Assigning clinical cues
- B. Defining characteristics
- C. Diagnostic reasoning NursingStoreRN
- D. Diagnostic labeling
Correct Answer: C
Rationale: The correct answer is C: Diagnostic reasoning. The nurse is using assessment data to analyze, interpret, and make a judgement about the patient's condition. This process involves critical thinking skills to develop a nursing diagnosis. Choice A (Assigning clinical cues) is incorrect because it refers to identifying specific signs and symptoms. Choice B (Defining characteristics) is incorrect as it pertains to the features of a diagnosed condition. Choice D (Diagnostic labeling) is incorrect because it focuses on naming a specific nursing diagnosis. Diagnostic reasoning encompasses the entire process of analyzing data, making connections, and formulating a nursing diagnosis based on critical thinking.
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. Hypertension
- B. Tachycardia
- C. Oliguria
- D. Tachypnea
Correct Answer: A
Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.
A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?
- A. Postural hypotension
- B. Postural Hypertension
- C. White coat hypertension
- D. White coat hypotension
Correct Answer: A
Rationale: The correct answer is A: Postural hypotension. This condition is characterized by a drop in blood pressure upon standing, leading to dizziness. The client's symptoms of dizziness upon standing, along with nosebleeds and blurred vision, are indicative of low blood pressure. Postural hypertension (B) is not a recognized medical condition; White coat hypertension (C) refers to elevated blood pressure readings in a medical setting due to anxiety; White coat hypotension (D) is not a recognized medical condition.