Nokea
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving.
A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient.
B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions.
C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.
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The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
- A. “Administer desmopressin while the suspension is cold.”
- B. “Your condition isn’t chronic, so you won’t need to wear a medical identification bracelet.”
- C. “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”
- D. “You won’t need to monitor your fluid intake and output after you start taking desmopressin.”
Correct Answer: C
Rationale: The correct answer is C: “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”
Rationale:
1. Desmopressin is available in intranasal form for diabetes insipidus.
2. Nasal discharge or blockage may prevent proper absorption of the medication.
3. Instructing the client about this potential issue ensures optimal drug effectiveness.
Summary:
A: Incorrect. Temperature of desmopressin suspension doesn't affect its efficacy.
B: Incorrect. A medical identification bracelet is necessary for chronic conditions like diabetes insipidus.
D: Incorrect. Monitoring fluid intake and output is crucial when taking desmopressin.
Nurse Norma’s discharge teaching for Mr. Aurelio, diagnosed with heart failure, should stress the significance of:
- A. maintaining a sedentary lifestyle most of the day
- B. obtain daily weights at the same time
- C. walking 2 miles daily
- D. maintaining a high fiber die
Correct Answer: B
Rationale: The correct answer is B: obtaining daily weights at the same time. This is crucial in monitoring fluid retention, a common issue in heart failure patients. Daily weights help detect early signs of fluid buildup. Option A is incorrect as physical activity is important for heart failure patients. Option C is incorrect as walking 2 miles daily may be too strenuous for some heart failure patients. Option D is incorrect as a high fiber diet is beneficial, but monitoring fluid retention is more critical in this case.
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
- A. Place the arm in the sling
- B. Apply cold soaks to the affected arm
- C. Introduce variations in styles of clothing
- D. Tie a tight bandage to the arm
Correct Answer: C
Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm.
A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality.
B: Applying cold soaks may help with swelling but does not directly address the client's self-image.
D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on the potential causes of their fatigue, leading to a more detailed and insightful response. This open-ended question allows the patient to explore various factors contributing to their fatigue, such as lifestyle habits, medical conditions, or emotional stressors.
Choice A focuses on stress, which may not be the primary cause of fatigue for the patient. Choice C is too specific and may not uncover other relevant information. Choice D assumes that sleep duration is the sole factor contributing to fatigue, neglecting other possible causes. Overall, choice B facilitates a more comprehensive discussion and helps the nurse gather valuable information to address the patient's concerns effectively.