Nokea
Which of the ff. nursing diagnoses is the focus of care for a patient with hypertension?
- A. Activity intolerance
- B. Impaired physical mobility
- C. Ineffective airway clearance
- D. Deficient knowledge
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. This nursing diagnosis is appropriate because educating the patient about hypertension, its management, lifestyle modifications, and medication adherence is crucial in improving outcomes. Activity intolerance (A) and impaired physical mobility (B) are not typically primary focuses for hypertension but may be secondary concerns. Ineffective airway clearance (C) is unrelated to hypertension. Therefore, D is the most relevant option for addressing the patient's needs.
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A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
- A. patients.” “If the nursing department uses this system, communication among nurses who work
- B. throughout the hospital may be enhanced.” “We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our
- C. unit.” “The NIC system provides one way to improve safe and effective documentation in the
- D. hospital’s electronic health record.”
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
A client metastatic ovarian cancer is prescribed cisplatin (Platinol). Before administering the first dose, the nurse reviews the client’s medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin?
- A. Erythromycin
- B. A cephalosporin
- C. A tetracycline
- D. An amino glycoside Situation: A client with ovarian cancer is prescribed hydroxyurea (Hydrea), an antimetabolite drug.
Correct Answer: D
Rationale: The correct answer is D: An aminoglycoside. Aminoglycosides, such as gentamicin or amikacin, can interact with cisplatin by increasing the risk of nephrotoxicity and ototoxicity. Both cisplatin and aminoglycosides have the potential to cause kidney damage, and when used together, the risk of kidney toxicity is significantly increased. This interaction is due to the additive effects on the kidneys. Therefore, it is crucial to monitor renal function closely and adjust the dosages of these drugs accordingly to prevent severe adverse effects.
Summary:
A: Erythromycin - Erythromycin is not known to have significant interactions with cisplatin.
B: A cephalosporin - Cephalosporins do not typically interact with cisplatin in a clinically significant manner.
C: A tetracycline - Tetracyclines are not known to cause significant interactions with
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
- A. A normal finding
- B. An abnormal finding
- C. A normal finding only in the older adult
- D. An abnormal finding only in the older adult
Correct Answer: A
Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
- A. Have him restrict fluid intake to 1000 mL/day
- B. Teach him to perform Kegel’s exercises 10 to 20 times per hour
- C. Reinsert the Foley catheter until he regains urinary control
- D. Reassure him that incontinence never lasts more than a few days
Correct Answer: B
Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (C) is not recommended as it can increase the risk of infection. Reassuring the patient (D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.