Nokea
Which nursing intervention is most appropriate for a client with multiple myeloma?
- A. Monitoring respiratory status
- B. Restricting fluid intake
- C. Balancing rest and activity
- D. Preventing bone injury
Correct Answer: D
Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, abnormal plasma cells can weaken bones, leading to fractures. Preventing bone injury involves educating the client on fall prevention, avoiding heavy lifting, and ensuring a safe environment. Monitoring respiratory status (A) is not the priority in multiple myeloma. Restricting fluid intake (B) is not directly related to managing multiple myeloma. Balancing rest and activity (C) is important for overall well-being but does not directly address the specific needs of a client with multiple myeloma.
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The most effective pharmacologic agent for the treatment of Parkinson’s disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for Parkinson's disease as it is converted to dopamine in the brain, replenishing dopamine levels which are depleted in Parkinson's. Selegiline and Symmetrel provide symptomatic relief but are not as effective as Levodopa. Permax is not commonly used due to its association with serious side effects like heart valve damage.
Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
- A. Do not leave the patient unattended at any time.
- B. Teach the patient not to bend over.
- C. Report sudden onset of acute pain.
- D. Apply sandbags to either side of the head.
Correct Answer: C
Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications.
A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain.
B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain.
D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.
A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? NursingStoreRN
- A. Patient wanders halls at night.
- B. Patient’s side rails are up with bed alarm activated.
- C. Patient denies pain while ambulating with assistance.
- D. Patient correctly states names of family members in the room.
Correct Answer: D
Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: Step 1: Mr. Dela Isla had a CVA, indicating the importance of managing his condition long-term.
Step 2: Drug compliance is crucial in preventing further strokes and managing existing health issues.
Step 3: Proper medication adherence can help control blood pressure, cholesterol, and blood sugar levels.
Step 4: Emergency numbers are important but secondary to long-term management.
Step 5: Relaxation techniques may be beneficial but not as essential as medication compliance for a CVA patient.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should always prioritize communication with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter could undermine the patient's autonomy and right to be involved in their care. It is important for the nurse to directly address the patient to gather accurate information and ensure patient-centered care. Making eye contact (A), leaning forward (C), and nodding periodically (D) are all appropriate communication techniques that show attentiveness and engagement with the patient, which are crucial in building rapport and trust.