Nokea
Which of the ff conditions are more likely to develop in a client who is relatively immobile for the rest of his or her life? Choose all that apply
- A. Bladder infection
- B. Constipation
- C. Calculus information
- D. Bladder inflammation
Correct Answer: A
Rationale: The correct answer is A: Bladder infection. Immobility can lead to urinary stasis, causing bacteria to multiply in the bladder, leading to a higher risk of bladder infections.
B: Constipation can also occur due to immobility, but it is not directly related to the urinary system.
C: Calculus formation is more related to factors like diet and hydration, not immobility.
D: Bladder inflammation can be a result of infection but is not as directly linked to immobility as bladder infections.
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Which nursing interventions can help prevent falls in a patient with Parkinson’s disease? Choose all answers that are correct. i.Keep the patient’s call light within reach ii.Apply a soft vest restraint when the patient is in bed iii.Avoid use of throw rugs iv.Maintain the patient’s bed in a low position v.Encourage the patient to be independent for as long as possible vi.Provide a cane or walker for ambulation
- A. 1, 4, 2005
- B. 1, 3, 4, 6
- C. 2, 3, 2006
- D. 2, 4, 5, 6
Correct Answer: A
Rationale: The correct answers are i. Keep the patient’s call light within reach, iii. Avoid use of throw rugs, and iv. Maintain the patient’s bed in a low position.
1. Keeping the call light within reach ensures the patient can easily call for assistance, reducing the risk of falls.
2. Avoiding throw rugs prevents tripping hazards that can lead to falls.
3. Maintaining the bed in a low position reduces the risk of injury if the patient falls out of bed.
The incorrect choices:
- Choice B includes answer 3 (Avoid use of throw rugs), which is correct, but also includes answer 6 (Provide a cane or walker for ambulation), which is not specific to fall prevention.
- Choice C includes answer 2 (Apply a soft vest restraint when the patient is in bed), which can increase the risk of falls due to restricted movement.
- Choice D includes answers that are not directly related to fall prevention, such as 2 (Apply a soft vest
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
- A. Presence of opportunistic infections
- B. Extent of immune system damage
- C. Level of the viral load
- D. Resistance to antigens
Correct Answer: B
Rationale: Step-by-step rationale:
1. CD4+ cells are a type of white blood cell crucial for immune function.
2. HIV targets and destroys CD4+ cells, leading to immune system damage.
3. Measuring CD4+ levels helps determine the extent of this damage.
4. Therefore, the correct answer is B.
Summary:
A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose.
C: Level of the viral load - Measured separately from CD4+ levels.
D: Resistance to antigens - CD4+ levels do not directly indicate resistance.
A nurse is collecting data from a home care client. In addition to information about the client’s health status, what is another observation the nurse should make?
- A. Number of rooms in the house
- B. Safety of the immediate environment
- C. Frequency of home visits to be made
- D. Friendliness of the client and family
Correct Answer: B
Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
- A. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help
- B. Gently raise Mr. Gabatan to a sitting position to see if the pain either
- C. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover him with any material available
- D. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
Correct Answer: C
Rationale: The correct answer is C because in cases of suspected spinal injury, it is crucial to keep the spine immobilized to prevent further damage. Rolling Mr. Gabatan onto his abdomen helps protect his spine by maintaining alignment. Placing a pad under his head provides support and covering him with any material available helps maintain his body temperature. Moving him without proper spinal precautions (options A, B, D) could worsen his condition. Seeking additional help is important, but ensuring spinal immobilization comes first. Sitting him up or moving him onto a flat piece of lumber can exacerbate spinal injuries. Therefore, option C is the most appropriate initial action.
A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he 'can’t live with this fear.' Which of the following diagnoses for this client is correctly written?
- A. Post-trauma syndrome related to being attacked
- B. Psychological overreaction related to being attacked
- C. Needs assistance coping with attack
- D. Mental distress related to being attacked
Correct Answer: A
Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. Post-trauma syndrome encompasses a range of symptoms following a traumatic event, such as flashbacks, anxiety, and emotional distress. The other choices are incorrect because they are either too vague (B: Psychological overreaction) or do not capture the specific nature of the client's symptoms (C: Needs assistance coping; D: Mental distress). Therefore, option A is the most appropriate diagnosis based on the client's presentation.