Nokea
Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: The correct answer is B, anaphylactic shock and angioedema, as it is the most severe complication of allergies and can be life-threatening. Anaphylactic shock can lead to airway constriction, severe drop in blood pressure, and organ failure. Angioedema can cause swelling of the face, lips, and throat, leading to difficulty breathing. Bronchitis (A) is a respiratory condition that can occur due to allergies but is not typically life-threatening. Cardiac arrest (C) is a serious complication but not directly related to allergies. Asthma and nasal polyps (D) are common allergic conditions but are not as immediately life-threatening as anaphylactic shock.
You may also like to solve these questions
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: Step 1: Providing referral to support groups and resources for information is essential for HIV positive clients as it offers emotional support, education, and access to resources for managing the condition.
Step 2: Support groups provide a safe space for clients to share experiences, seek advice, and reduce feelings of isolation.
Step 3: Resources for information help clients stay informed about their condition, treatment options, and lifestyle modifications.
Step 4: Referral to support groups and resources promotes holistic care and enhances the client's overall well-being.
Summary: Choices A, B, and C are incorrect as they do not address the specific needs of HIV positive clients and may even pose risks to their health. Option D is the most appropriate intervention as it focuses on comprehensive support and empowerment for clients.
Which nursing action is most appropriate for the weak patient with osteoporosis?
- A. Maintain bedrest
- B. Ambulate with assistance
- C. Encourage fluids
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Ambulate with assistance. Ambulating helps prevent further bone loss and strengthens muscles, important for osteoporosis patients. Bedrest can worsen bone density loss. Encouraging fluids and providing a high-protein diet are important for overall health but do not directly address the weakness associated with osteoporosis.
A patient with a history of haemophilia A arrives in the emergency department complaining of a “funny feeling” in his elbow. The patient states that he thinks he is bleeding into the joint. Which response by the nurse is correct?
- A. Palpate the patient’s elbow to assess for swelling.
- B. Notify the physician immediately and expect an order for factor VIII.
- C. Prepare the patient for an x-ray examination to determine whether bleeding is occurring.
- D. Apply heat to the patient’s elbow and wait for the physician to examine the patient.
Correct Answer: B
Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention.
Choices A, C, and D are incorrect:
A: Palpating the elbow could exacerbate the bleeding and cause further damage.
C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding.
D: Applying heat can increase blood flow to the joint, worsening the bleeding.
What is the primary purpose of the implementation step in the nursing process?
- A. To establish priorities for the client’s care
- B. To carry out the plan of care
- C. To identify client outcomes
- D. To validate nursing diagnoses
Correct Answer: B
Rationale: The correct answer is B: To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (A) is done during the planning phase, identifying client outcomes (C) is part of the evaluation phase, and validating nursing diagnoses (D) is typically done during the assessment phase, not implementation.
A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
- A. Request that the family leave, so the patient can rest.
- B. Ask the patient to return to the room, so the nurse can inspect the abdomen.
- C. Ask the patient when the last bowel movement was and to lie down on the sofa. Tell the patient that the dinner tray will be ready in 15 minutes and that may help
- D. the stomach feel better.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen.
Rationale:
1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues.
2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately.
3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support.
Summary:
A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system.
C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort.
D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.