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Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
- A. orthopnea
- B. fever
- C. weight loss
- D. calf pain A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET O
Correct Answer: A
Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat.
Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe.
Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection.
Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF.
Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF.
Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.
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For a client with sickle cell anemia, how does the nurse assess for jaundice?
- A. The nurse assesses mental status, verbal ability, and motor strength
- B. The nurse observes the joints for signs of swelling
- C. The nurse inspects the skin and sclera for jaundice
- D. The nurse collects a urine specimen
Correct Answer: C
Rationale: The correct answer is C because jaundice is a common manifestation of sickle cell anemia due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for the characteristic yellow discoloration indicating jaundice. This assessment is specific to identifying jaundice, which is directly related to the disease process.
Choice A is incorrect as it relates to assessing neurological function, not jaundice. Choice B is incorrect as joint swelling is not a typical sign of jaundice in sickle cell anemia. Choice D is incorrect as a urine specimen is not used to assess jaundice; skin and sclera inspection are more appropriate.
The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
- A. Has intercourse with just the spouse
- B. Makes a donation of a pint of whole blood
- C. Limits sexual contact to those without HIV antibodies
- D. Uses a'condom each time there is a sexual intercourse
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV.
2. It eliminates the risk of contracting HIV from multiple sexual partners.
3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV.
4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission.
Summary:
- Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV.
- Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
- A. antidiuretic hormone (ADH).
- B. follicle-stimulating hormone (FSH).
- C. thyroid-stimulating hormone (TSH).
- D. luteinizing hormone (LH).
Correct Answer: A
Rationale: The correct answer is A: antidiuretic hormone (ADH). In diabetes insipidus, there is a deficiency of ADH, which regulates water balance by reducing urine output. Without ADH, excessive urination and thirst occur. FSH, TSH, and LH are not related to water balance regulation. FSH and LH are involved in reproductive functions, while TSH regulates thyroid hormone production. Therefore, the nurse should focus on educating the client about the importance of ADH in managing diabetes insipidus.
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
- A. Stand as far away from the implant as possible and call for help.
- B. Pick up the implant with long-handled forceps and place it in a lead-lined container.
- C. Leave the room and notify the radiation therapy department immediately.
- D. Put the implant back in place, using forceps and a shield for self-protection, and call for help.
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice C) delays the immediate action needed to prevent unnecessary radiation exposure.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A because completing a comprehensive database is part of the first phase of the nursing process, which is assessment. During assessment, the nurse gathers data about the patient's health status. This information is crucial for identifying health problems, developing nursing diagnoses, planning interventions, and evaluating outcomes.
Choice B is incorrect because identifying nursing diagnoses is part of the second phase, which is diagnosis. Choice C is incorrect as intervening based on priorities of patient care is part of the third phase, which is planning. Choice D is incorrect because determining whether outcomes have been achieved is part of the fourth phase, which is evaluation.