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Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: The correct answer is D, a behavior change. Urinary retention in older adults with a neurologic deficit can manifest as a behavior change, such as increased agitation, confusion, or restlessness due to discomfort from the inability to empty the bladder. Amnesia (A) is memory loss and not directly related to urinary retention. Hypertension (B) and hypotension (C) are related to blood pressure regulation and are not specific signs of urinary retention. In contrast, a behavior change (D) is a common and characteristic sign indicating urinary retention in this population.
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The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?
- A. Cognitive
- B. Interpersonal
- C. Psychomotor
- D. Judgmental
Correct Answer: B
Rationale: The correct answer is B: Interpersonal. The nurse is using interpersonal skills by establishing trust and communicating with the patient before administering the injection. This helps build rapport and alleviate anxiety. Cognitive skills involve problem-solving and critical thinking, not direct patient interaction. Psychomotor skills relate to physical tasks like giving injections. Judgmental skills involve making decisions based on critical thinking, not directly related to patient communication.
A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse document?
- A. Decreased cardiac output related to altered myocardial contractility.
- B. Patient needs a low-fat diet related to inadequate heart perfusion. NursingStoreRN
- C. Offer a low-fat diet because of heart problems.
- D. Acute heart pain related to discomfort.
Correct Answer: A
Rationale: The correct answer is A because it follows the correct format of a nursing diagnosis: "Problem related to Etiology." In this case, "Decreased cardiac output" is the problem, and "altered myocardial contractility" is the cause. This format helps identify the specific issue and its underlying cause, allowing for targeted interventions. Choice B is incorrect as it doesn't follow the problem-etiology format and lacks specificity. Choice C is also incorrect as it lacks a clear nursing diagnosis and specific etiology. Choice D is incorrect as it presents a symptom rather than a nursing diagnosis with an associated cause. Overall, choice A is the best option as it provides a clear, specific nursing diagnosis that guides appropriate nursing interventions.
The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone
- B. Observe for swelling of the neck, tracheal deviation, and severe pain
- C. Evaluate the quality of the client’s voice postoperatively, noting any dastric changes
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
Correct Answer: D
Rationale: The correct answer is D: Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. After a thyroidectomy, the parathyroid glands may be inadvertently damaged, leading to hypocalcemia. Muscle twitching and numbness/tingling are early signs of hypocalcemia. The nurse should monitor for these symptoms to detect and address hypocalcemia promptly.
Choice A is incorrect as monitoring thyroid-stimulating hormone levels is not related to hypocalcemia. Choice B is incorrect as it describes signs of potential complications like bleeding or airway obstruction, not hypocalcemia. Choice C is incorrect as changes in voice quality and gastric issues are not specific to hypocalcemia.
A patient is diagnosed with acute bacterial conjunctivitis. In providing patient teaching the nurse would tell the patient that this condition is more commonly known as which of the following?
- A. Glaucoma
- B. Color blindness
- C. Astigmatism
- D. Pinkeye
Correct Answer: D
Rationale: The correct answer is D: Pinkeye. Acute bacterial conjunctivitis is commonly referred to as "pinkeye" due to the characteristic pink or red appearance of the eye. This condition is caused by a bacterial infection of the conjunctiva, the thin membrane that covers the white part of the eye and inner eyelids. The term "glaucoma" (A) refers to a different eye condition characterized by increased intraocular pressure, while "color blindness" (B) is a genetic condition affecting color vision. "Astigmatism" (C) is a refractive error related to the shape of the cornea or lens, not an infection of the eye. Therefore, the correct answer is D as it accurately identifies the common name for acute bacterial conjunctivitis.
Management of hypercalcemia includes all of the following actions except administration of:
- A. Fluid to dilute the calcium le⁺vels
- B. The diuretic furosemide (Lasix), without saline, to increase calcium excretion through kidneys
- C. Inorganic phosphate salts
- D. Intravenous phosphate therapy
Correct Answer: B
Rationale: The correct answer is B because administration of the diuretic furosemide without saline is not recommended for managing hypercalcemia. Furosemide can lead to volume depletion and potentially exacerbate hypercalcemia by concentrating calcium levels in the blood.
A: Fluid administration helps dilute calcium levels by increasing urine output.
C: Inorganic phosphate salts can bind with calcium in the gut, reducing absorption.
D: Intravenous phosphate therapy can help lower calcium levels by promoting calcium-phosphate complex formation.
In summary, B is incorrect as it may worsen hypercalcemia, while A, C, and D are valid strategies for managing hypercalcemia.