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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For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?
- A. Headache
- B. Pruritus
- C. Vomiting
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.
While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?
- A. Recommend a dermatological consult to the physician.
- B. Note the location of the mole and contact the physician via telephone.
- C. Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
- D. Remove the mole with a sharp debridement technique, following approval from the charge nurse.
Correct Answer: C
Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.
Which client should the nurse see first?
- A. Recurring crushing chest pain
- B. Needing an IV for surgery in 5 minutes
- C. Needing PCA morphine for pain control post-hysterectomy
- D. Waiting to get back to bed after sitting in a chair for 30 minutes
Correct Answer: A
Rationale: The client presenting with recurring crushing chest pain should be seen first as this symptom could indicate a myocardial infarction (MI), which is a life-threatening condition requiring immediate attention. Assessing and managing potential cardiac issues take priority over other concerns like needing an IV for surgery, pain control post-hysterectomy, or assistance with mobility. While all clients require care, addressing the chest pain promptly is crucial to ensure the client's safety and well-being.
The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?
- A. Muscle tetany
- B. Syncope
- C. Numbness
- D. Anxiety
Correct Answer: D
Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.
The power a healthcare professional exerts when working to accomplish goals and effect change in an agency or policy is considered what type of power?
- A. political
- B. personal
- C. positional
- D. professional
Correct Answer: A
Rationale: Political power is the correct answer in this scenario. It stems from the ability to navigate systems, agencies, or policies to bring about change. Personal power is related to charisma and self-confidence in informal leadership roles. Positional power comes from holding a specific authority in a formal position. Professional power is derived from expertise in a particular area of practice. Therefore, in the context of effecting change in an agency or policy, political power is the most relevant type of power.