Nokea
Which of the following illustrates a common error when writing client outcomes?
- A. Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
- B. Client will demonstrate correct sequence of exercises by next office visit.
- C. Client will be less anxious and fearful before and after surgery.
- D. On discharge, client will list five symptoms of infection to report.
Correct Answer: C
Rationale: The correct answer is C because it does not provide a specific, measurable outcome. It is vague and subjective, making it difficult to assess and track progress. In contrast, choices A, B, and D are all specific, measurable, and time-bound goals, making them more effective for evaluating client outcomes. Choice A specifies the amount of fluid intake and the time frame, choice B sets a clear deadline for demonstrating a skill, and choice D outlines a specific task to be completed upon discharge. Therefore, C is the correct answer as it lacks the clear criteria needed for effective outcome evaluation.
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Which of the following settings is most therapeutic for an agitated head-injured patient?
- A. A day room with family visitors and variety of caregivers
- B. A semiprivate room with one or two consistent caregivers
- C. A ward with other head-injured patients and volunteers to assist with needs
- D. A hallway near the nurse’s station with adequate sensory stimulation
Correct Answer: B
Rationale: The correct answer is B. A semiprivate room with one or two consistent caregivers is the most therapeutic setting for an agitated head-injured patient. Here's the rationale:
1. Consistency: Having one or two consistent caregivers provides the patient with a stable and familiar environment, which can help reduce agitation.
2. Privacy: A semiprivate room offers more privacy compared to a day room or a ward, which can help minimize external stimuli and promote relaxation.
3. Individualized care: In a semiprivate room, caregivers can focus more on the specific needs of the patient, leading to better management of agitation.
4. Reduced distractions: Being in a semiprivate room minimizes distractions and noise, which can be overwhelming for an agitated head-injured patient.
Summary:
A, C, and D are incorrect because they do not offer the same level of consistency, privacy, individualized care, and reduced distractions as a semiprivate room with one
The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The correct answer is D because polyuria is a common complication of hypophysectomy, the surgical removal of the pituitary gland. The pituitary gland plays a crucial role in regulating water balance in the body, and its removal can lead to excessive urine production. Choices A, B, and C are incorrect because a decrease in stress does not typically cause polyuria, diabetes mellitus is not an immediate complication of surgery, and polyuria is not an expected result of pituitary gland removal.
Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
- A. Because their defense mechanisms are less efficient
- B. Because they are prone to fluid overload
- C. Because they are prone to reduced renal efficiency
- D. Because they have inadequate intake of dietary fiber
Correct Answer: E
Rationale: The correct answer is not provided in the choices. However, if I were to choose from the given options, the most appropriate would be C: "Because they are prone to reduced renal efficiency." This is important because older adults may have decreased kidney function, leading to potential complications with IV therapy. Option A is incorrect as defense mechanisms are not directly related to monitoring IV therapy. Option B is incorrect as fluid overload is a general concern with IV therapy regardless of age. Option D is irrelevant to the need for monitoring IV therapy in older adults.
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
- A. Probenecid (Benemid)
- B. Cytarabine (ara-C, cystosine arabinoside [Cytosar-U])
- C. Thioguanine (6-thioguanine, 6-TG)
- D. Leucovorin (Citrovorum factor or folinic acid [wellcovirin])
Correct Answer: D
Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?
- A. Discomfort while changing position
- B. Reports pain as a 7 on a 0 to 10 scale
- C. Disruption of tissue integrity
- D. Dull headache
Correct Answer: C
Rationale: The correct answer is C: Disruption of tissue integrity. Acute pain is typically caused by tissue damage or injury, such as a cut or a burn. The nurse would use this assessment data as an etiology for acute pain because it directly relates to the source of the pain. Discomfort while changing position (A) is a symptom of pain but does not provide the underlying cause. Reports pain as a 7 on a 0 to 10 scale (B) is a pain intensity rating and does not explain the cause of the pain. Dull headache (D) is a specific type of pain but is not relevant to the given scenario of tissue disruption.