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Which of the following examples of client data needs to be validated?
- A. A client has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a client with a respiratory infection documents fever and chills.
- D. A client in a nursing home states that she is unable to eat the food being served.
Correct Answer: A
Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight.
- Choice B is about interpreting physical signs, not client data validation.
- Choice C involves documenting objective findings, not validating client information.
- Choice D pertains to a client's complaint, not necessarily requiring validation.
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The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
- A. Ask the nursing assistive personnel if the wound looks better.
- B. Document the progress of wound healing as “better” in the chart.
- C. Measure the wound and observe for redness, swelling, or drainage.
- D. Leave the dressing off the wound for easier access and more frequent assessments.
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications.
- Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately.
- Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status.
- Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?
- A. Stop the bleeding
- B. Take his vital signs
- C. Check his airway
- D. Find out what happened from eyewitnesses NEUROLOGIC DISORDERS
Correct Answer: C
Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.
Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson’s or Huntington’s diseases, or even epilepsy?
- A. Because clients suffer from depression, anxiety, and inability to perform basic self care
- B. Because clients become paralytic throughout the body
- C. Because the clients bone become weak, brittle, and painful to even move
- D. Because clients generally become very aggressive and violent with other people CARING FOR CLIENTS WITH NEUROLOGIC DEFICITS
Correct Answer: A
Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks.
Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.
Mrs. Tan is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which of the following is the priority goal for her immediately after the procedure?
- A. prevent fluid volume deficit
- B. maintain blood pressure control
- C. decrease myocardial contractility
- D. minimize dyspnea
Correct Answer: B
Rationale: The correct answer is B: maintain blood pressure control. After PTCA, the priority goal is to ensure stable hemodynamics. Maintaining blood pressure control is crucial to prevent complications such as bleeding or thrombosis. Choices A, C, and D are incorrect because preventing fluid volume deficit, decreasing myocardial contractility, and minimizing dyspnea are not immediate priorities post-PTCA. Oxygenation and hemodynamic stability take precedence over these concerns.
A client takes prednisone (Deltasone), as prescribed, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as:
- A. Tetany and tremors
- B. Fluid retention and weight gain
- C. Anorexia and weight loss
- D. None of the above
Correct Answer: B
Rationale: The correct answer is B: Fluid retention and weight gain. Prednisone is a corticosteroid that can cause fluid retention and weight gain as common adverse reactions. Here's the rationale: Prednisone is known to increase sodium and water retention in the body, leading to fluid retention and subsequent weight gain. This occurs due to the drug's impact on the body's electrolyte balance. Tetany and tremors (Choice A) are not common adverse reactions associated with prednisone use. Anorexia and weight loss (Choice C) are also not typical reactions, as prednisone is more likely to cause weight gain. Choice D, "None of the above," is incorrect as prednisone commonly causes fluid retention and weight gain as adverse reactions.