Nokea
Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
- A. Taking a health history and performing a physical exam prior to the procedure
- B. Instructing the client about how to care for his colostomy stoma
- C. Developing goals that state the client will ambulate three times a day
- D. Determining that the client may need more support at home after dismissal
Correct Answer: B
Rationale: The correct answer is B. Instructing the client about how to care for his colostomy stoma is an example of the intervention phase as it involves providing specific guidance to the client on post-operative care. This intervention directly addresses the client's needs post-colostomy and helps promote optimal healing and adjustment.
Choice A is part of the assessment phase, which occurs before the intervention phase. Choice C involves goal-setting, which is part of the planning phase. Choice D pertains to discharge planning, which is part of the evaluation phase.
In summary, Choice B is the correct answer because it aligns with the intervention phase of the nursing care plan, focusing on providing necessary education and support to the client regarding colostomy care.
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A nurse is performing an end-of-shift count of narcotics kept in the locked cabinet. The narcotic log states there should be 26 oxycodone pills left, but there are only 24 in the drawer. What is the first action of the nurse?
- A. Perform the count again
- B. Contact the pharmacy to determine if the narcotic log is incorrect
- C. Check with the last nurse to sign out narcotics from the system
- D. Notify the house supervisor that narcotic medications are missing
Correct Answer: A
Rationale: The correct answer is A: Perform the count again. The nurse should double-check the count to ensure accuracy before taking further action. Performing the count again helps to rule out any possible errors in the initial count. This step ensures that the discrepancy is not due to a simple mistake or oversight. Contacting the pharmacy (B), checking with the last nurse who signed out narcotics (C), or notifying the house supervisor (D) should be done after confirming the discrepancy through a recount. The first action should always be to verify the count internally before involving external parties or escalating the issue.
Which of the following types of antipsychotic medications is most likely to produce extrapyramidal effects?
- A. Atypical antipsychotic drugs
- B. First-generation antipsychotic drugs
- C. Third-generation antipsychotic drugs
- D. Dopamine system stabilizers
Correct Answer: B
Rationale: The correct answer is B: First-generation antipsychotic drugs. These medications primarily block dopamine receptors in the brain, leading to extrapyramidal effects such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. These side effects are less common with atypical antipsychotic drugs (choice A) due to their different receptor profiles. Third-generation antipsychotic drugs (choice C) and dopamine system stabilizers (choice D) are newer classes of medications with reduced extrapyramidal effects compared to first-generation drugs. Therefore, the most likely culprit for producing extrapyramidal effects among the options provided is the first-generation antipsychotic drugs.
Which of the following is an example of a living will?
- A. A client's son has been appointed to make his healthcare decisions if he becomes incapacitated
- B. A client has designated which of his children will receive his home and property before he dies
- C. A client has instructions that he does not want to be resuscitated through chest compressions if his heart stops beating
- D. A client designates what type of burial or cremation services he would want after his death
Correct Answer: C
Rationale: The correct answer is C because a living will is a legal document that outlines a person's preferences for medical treatment in case they are unable to communicate their wishes. In this case, the client's instruction not to be resuscitated through chest compressions if his heart stops beating is an example of a living will. This choice specifically addresses medical treatment preferences during a critical health situation.
Choices A, B, and D are incorrect because they all involve decisions or instructions that pertain to events or actions after the client's death, rather than specifying medical treatment preferences while the client is alive. Choice A involves appointing someone to make healthcare decisions, choice B involves designating inheritance of property, and choice D involves specifying burial or cremation services. These choices do not align with the purpose of a living will, which is to provide guidance for medical treatment decisions during the client's lifetime.
A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?
- A. Contact the physician to amend the order for the client
- B. Document an account of the situation to ensure adequate coverage of details
- C. Consult with the medical ethics committee to determine a safe and workable solution
- D. Speak with the chief nursing officer to change the policy governing this situation
Correct Answer: A
Rationale: The correct initial step is to choose option A: Contact the physician to amend the order for the client. This is the most appropriate action because the conflict arises from the surgeon's policy, which can potentially be changed with physician involvement. By discussing the situation with the physician, the nurse can advocate for the family's wishes and potentially negotiate a compromise. This step prioritizes the client's and family's needs while also respecting the surgeon's authority. Options B, C, and D are not the initial steps because they involve escalating the situation before attempting direct communication with the physician, which can be seen as bypassing the appropriate chain of command.
A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?
- A. Knowledge Deficit related to post-partum blood loss
- B. Self-Care Deficit related to post-partum neglect
- C. Fluid Volume Deficit related to post-partum hemorrhage
- D. Body Image Disturbance related to body changes after delivery
Correct Answer: C
Rationale: The correct answer is C: Fluid Volume Deficit related to post-partum hemorrhage. This nursing diagnosis is most appropriate because excessive vaginal bleeding can lead to a significant loss of blood volume, potentially resulting in hypovolemia. It is crucial to address this issue promptly to prevent further complications. Choice A is incorrect as the primary concern is the fluid volume deficit, not knowledge deficit. Choice B is incorrect as self-care deficit is not the priority in this situation. Choice D is incorrect as body image disturbance is not directly related to the excessive bleeding.