Nokea
Which nursing diagnosis has the highest priority for a client with insomnia?
- A. Ineffective breathing pattern
- B. Disturbed sensory perception
- C. Ineffective coping
- D. Sleep deprivation
Correct Answer: A
Rationale: The correct answer is 'A: Ineffective breathing pattern.' When a client presents with insomnia, assessing for underlying causes is crucial. Sleep apnea, an airway issue, may be a contributing factor to the client's insomnia, making 'Ineffective breathing pattern' the priority. 'Disturbed sensory perception' focuses on alterations in touch, taste, or vision, which are not directly related to insomnia. 'Ineffective coping' addresses a client's inability to manage stress, which, although important, is not the priority in this case. 'Sleep deprivation' is a consequence of insomnia rather than a primary nursing diagnosis.
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A healthcare professional is reviewing a patient's arterial blood gas values. Which of the following conditions apply under the following values?
pH- 7.49
Bicarbonate ion 24 mEq/dl
PaCO2 - 31 mmHg
PaO2 - 52 mmHg
FiO2 - 0.22
- A. respiratory acidosis
- B. respiratory alkalosis
- C. metabolic acidosis
- D. metabolic alkalosis
Correct Answer: B
Rationale: The given blood gas values indicate respiratory alkalosis. A high pH and low PaCO2 level are consistent with respiratory alkalosis. In this scenario, no compensation for the alkalosis is noted, ruling out metabolic acidosis or alkalosis. Metabolic conditions would usually involve changes in bicarbonate levels, which remain within the normal range in this case.
To determine the standards of care for the institution, the nurse should consult?
- A. Organizational Chart
- B. Personnel policies
- C. Policies and procedure manual
- D. Job descriptions
Correct Answer: C
Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.
What type of diet is appropriate for a client with chronic cirrhosis?
- A. High calorie, low protein
- B. High protein, high calorie
- C. Low fat, low sodium
- D. High calorie, low sodium
Correct Answer: A
Rationale: The correct diet for a client with chronic cirrhosis is high calorie, low protein. Cirrhosis can lead to impaired protein metabolism, making it essential to limit protein intake. High-calorie foods help meet the client's energy needs. Choice B (High protein, high calorie) is incorrect because high protein intake can worsen hepatic encephalopathy. Choice C (Low fat, low sodium) is not the most appropriate diet for cirrhosis as the focus should be on calories and protein. Choice D (High calorie, low sodium) does not address the need to restrict protein intake, which is crucial in cirrhosis.
Which of the following individuals is at the highest risk for suicide?
- A. 76-year-old widow with chronic renal failure
- B. 19-year-old with new SSRI therapy
- C. 28-year-old post-partum crying weekly
- D. 50-year-old client with obsessive-compulsive disorder (OCD) and depression
Correct Answer: A
Rationale: The correct answer is the 76-year-old widow with chronic renal failure. Elderly individuals with chronic diseases, especially men, are at very high risk for suicide. The other choices, although they may be vulnerable populations, do not carry as high a risk for suicide. The 19-year-old with new SSRI therapy may actually have a lower risk as they are receiving treatment. The 28-year-old post-partum individual is experiencing a common emotional response after childbirth, which is not necessarily indicative of a high suicide risk. The 50-year-old with OCD and depression is at risk but not as high as elderly individuals with chronic illness.
Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit?
- A. Reduction of anxiety
- B. Referral to community resources
- C. Identification of lifestyle changes
- D. Verbalization of energy-conservation techniques
Correct Answer: C
Rationale: The most important goal for a client admitted to the cardiac rehabilitation unit is the identification of lifestyle changes. This is crucial in promoting cardiovascular health and preventing future cardiac issues. Lifestyle changes such as diet modifications, exercise routines, smoking cessation, and stress management play a significant role in improving the overall cardiovascular well-being of the patient. While reducing anxiety, referring to community resources, and verbalizing energy-conservation techniques are all important aspects of care, identifying lifestyle changes is the primary focus in helping the client achieve long-term cardiovascular wellness.