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Which of the following is NOT APPROPRIATE description and written in the Nurses notes when a patient has a pitting edema?
- A. Degree of edema
- B. Duration of indentation
- C. Degree of temperatur e
- D. Depth of edema
Correct Answer: C
Rationale: When documenting pitting edema in a patient's notes, it is important to include details such as the degree of edema (A), duration of indentation (B), and depth of edema (D) as these parameters are relevant in assessing the severity of the condition and monitoring changes over time. However, mentioning the degree of temperature (C) is not directly related to assessing pitting edema. Temperature is typically assessed as part of a general physical assessment for signs of infection or inflammation and is not specifically needed when documenting pitting edema.
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Which of the following is the initial teachinggiven to the patient with ALS having problems in communication?
- A. Referring the client to a speech therapist
- B. Documenting any change in the elimination functions
- C. Use of pre-signals before the loss of speech
- D. Continue to use therapeutic communication technique
Correct Answer: C
Rationale: In ALS (Amyotrophic Lateral Sclerosis), communication difficulties may occur as the disease progresses and affects the muscles responsible for speech. It is crucial to initiate early measures to assist the patient in communicating effectively. Using pre-signals before the loss of speech can be helpful in maintaining communication with the patient. These pre-signals can include gestures, writing tools, communication boards, or technology-assisted communication devices. By introducing and practicing these pre-signals early on, the patient can adapt and utilize alternative communication methods before the loss of speech becomes more challenging. This proactive approach can significantly improve the patient's ability to communicate and maintain a sense of connection with others.
Before the education plan of the staff nurse can be finalized and implemented, it is best that it is reviewed by the
- A. Nurse supervisor
- B. Head nurse
- C. Medical Director
- D. Chief nurse
Correct Answer: A
Rationale: Before finalizing and implementing the education plan for the staff nurse, it is important to have the plan reviewed by the nurse supervisor. The nurse supervisor is directly responsible for overseeing the staff nurses and their education and training needs. They have a good understanding of the staff nurse's current skills, areas for improvement, and training requirements. By involving the nurse supervisor in the review process, you can ensure that the education plan is aligned with the overall goals and needs of the nursing staff and the department. Additionally, the nurse supervisor can provide valuable input and insights to help tailor the education plan to meet the specific needs of the staff nurses under their supervision.
The female client who is very anxious and fidgety is blowing off to much carbon dioxide develops tingling sensation of the lips and fingers and is not able to control her respirations. The MOST appropriate nursing intervention for this client is to _____.
- A. Instruct the client to blow her nose and take deep breath
- B. Administer oxygen
- C. Have the client breath into a paper bag
- D. Administer IV fluids as ordered
Correct Answer: C
Rationale: The client is experiencing symptoms of hyperventilation, a condition that occurs when there is excessive elimination of carbon dioxide from the body. Breathing into a paper bag can help by allowing the client to rebreathe carbon dioxide, which can help restore the balance of gases in the blood and alleviate the tingling sensations in the lips and fingers. This technique is commonly used to help regulate breathing in cases of hyperventilation. Administering oxygen (choice B) may not be necessary as the issue lies with an imbalance of carbon dioxide, not a lack of oxygen. Instructing the client to blow her nose and take deep breaths (choice A) may not address the underlying problem effectively. Administering IV fluids (choice D) is not relevant to the client's symptoms of hyperventilation.
As a nurse you are guided that pain is usually described BEST as a phenomenon which is a ________.
- A. Neurologic activation nociceptors
- B. Subjective unpleasant experience
- C. Adaptive mechanism to a stimulus
- D. Creation of one's imagination
Correct Answer: B
Rationale: Pain is best described as a subjective unpleasant experience because it is unique to each individual and is influenced by a variety of factors including emotional, psychological, and cultural elements. Pain cannot be objectively measured or quantified, and therefore it is considered a subjective experience that is reported by the person experiencing it. This is why pain is often assessed using self-report scales and tools to capture the individual's perception of their pain intensity and quality.
A patient presents with pallor, fatigue, and dyspnea on exertion. Laboratory tests reveal a low hemoglobin level, low MCV, and elevated red blood cell distribution width (RDW). Which of the following conditions is most likely to cause these findings?
- A. Iron deficiency anemia
- B. Thalassemia
- C. Anemia of chronic disease
- D. Megaloblastic anemia
Correct Answer: A
Rationale: #NAME?