Nokea
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
- A. Assessment data should be collected continuously.
- B. Assess your client after receiving the nursing report and again before giving a report to the next shift.
- C. Assess your client at least hourly if vital signs are unstable, and every two hours if stable.
- D. Assessment data should be collected prior to the physician rounding on the unit.
Correct Answer: A
Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.
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There seems to be a positive correlation between type 2 diabetes mellitus and:
- A. Hypotension
- B. Obesity
- C. Kidney dysfunction
- D. Sex
Correct Answer: B
Rationale: The correct answer is B: Obesity. Obesity is a well-established risk factor for developing type 2 diabetes mellitus due to the increased resistance of body cells to insulin. This leads to elevated blood sugar levels. Hypotension (A) is low blood pressure and is not typically associated with type 2 diabetes. Kidney dysfunction (C) is a complication of diabetes but not a direct correlation. Sex (D) does not have a direct link to the development of type 2 diabetes. Therefore, the most likely correlation is with obesity due to its impact on insulin resistance.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.
Clinical manifestations of Huntington’s disease include:
- A. Abnormal involuntary movements (chorea)
- B. Intellectual decline
- C. Emotional disturbances
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Abnormal involuntary movements are a hallmark feature, while cognitive decline and emotional disturbances are also commonly observed. Therefore, all three manifestations are typically present in individuals with Huntington's disease. Choices A, B, and C are incorrect because each of these symptoms alone does not encompass the full spectrum of clinical manifestations seen in Huntington's disease.
A client with allergic rhinitis is prescribed loratadine (Claritin). On a follow-up visit, the client tells the nurse, “I take one 10-mg of Claritin with a glass of water two times daily”. The nurse concludes that the client requires additional teaching about this medication because:
- A. Loratadine isn’t available in 10mg tablets
- B. Loratadine should be taken on an empty stomach
- C. Loratadine should be taken once daily for allergenic rhinitis
- D. Claritin isn’t the trade name for loratadine
Correct Answer: C
Rationale: Rationale:
1. Loratadine is typically dosed once daily, not twice daily, for allergic rhinitis.
2. Taking it twice daily may increase the risk of side effects without added benefit.
3. The client's dosing schedule reflects a misunderstanding of the medication regimen.
4. Option A is incorrect because loratadine is available in 10mg tablets.
5. Option B is incorrect as loratadine can be taken with or without food.
6. Option D is incorrect as Claritin is a common trade name for loratadine.
The nurse administers chemotherapeutic drugs to a client with cancer. What adverse effects are most common?
- A. Painful mouth sores
- B. Nausea and vomiting
- C. Frequent diarrhea
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapeutic drugs commonly cause nausea and vomiting due to their effect on the gastrointestinal system. This is because these drugs can irritate the stomach lining and trigger the vomiting center in the brain. Nausea and vomiting are well-documented side effects of chemotherapy and are often managed with antiemetic medications.
A: Painful mouth sores are a common side effect of some chemotherapeutic drugs, but they are not the most common adverse effect.
C: Frequent diarrhea can occur as a side effect of chemotherapy, but it is less common than nausea and vomiting.
D: Constipation is not a common adverse effect of chemotherapeutic drugs; in fact, diarrhea is more commonly seen.