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Which of the following nursing interventions is correctly categorized as collaborative?
- A. Administering medications as prescribed by the healthcare provider
- B. Ordering a low-sodium diet for a hypertensive client
- C. Providing health education about medication side effects
- D. Monitoring a client’s response to an intervention initiated by another healthcare professional
Correct Answer: D
Rationale: The correct answer is D because monitoring a client's response to an intervention initiated by another healthcare professional is a collaborative nursing intervention. This involves working together with other healthcare team members to assess the client's progress and adjust care as needed. It promotes continuity of care and ensures that the client's needs are met effectively.
A: Administering medications is typically an independent nursing intervention.
B: Ordering a low-sodium diet is within the scope of a nurse's independent practice.
C: Providing health education is often considered an independent nursing intervention unless it involves collaboration with other team members.
In summary, choice D is the correct answer as it exemplifies collaborative care within a healthcare team.
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Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: The correct answer is B: Pallor. Pallor, which refers to paleness of the skin, is an early sign of anemia due to decreased red blood cell levels. Anemia causes reduced oxygen delivery to tissues, leading to paleness. Palpitations (A) may occur in anemia but are not an early sign. Glossitis (C) and weight loss (D) are not typically early signs of anemia and are more commonly associated with other health conditions.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.
A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
- A. Assessment
- B. Planning
- C. Implementation NursingStoreRN
- D. Evaluation
Correct Answer: D
Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation involves determining if the patient's condition has improved and if the expected outcomes have been met. The nurse assesses the patient's progress, compares it to the expected outcomes set during planning, and determines the effectiveness of the interventions implemented. This step ensures that the care provided is meeting the patient's needs and helps in making any necessary adjustments to the care plan.
Incorrect choices:
A: Assessment - This step involves gathering information about the patient's condition and needs at the beginning of the nursing process.
B: Planning - Involves setting goals and developing a plan of care based on the assessment data.
C: Implementation - Involves carrying out the interventions outlined in the care plan to meet the patient's goals.
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient’s plan of care?
- A. Deficient fluid volume
- B. Imbalanced nutrition more than body requirements
- C. Excess fluid volume
- D. Noncompliance
Correct Answer: C
Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance.
A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit.
B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake.
D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.
Which of the ff should qualify as an abnormal result in a Romberg test?
- A. Hypotension
- B. Swaying, losing balance, or arm drifting
- C. Sneezing and wheezing
- D. Excessive cerumen in the outer ear
Correct Answer: B
Rationale: Step-by-step rationale:
1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception.
2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal.
3. Hypotension (choice A) is not directly related to the Romberg test.
4. Sneezing and wheezing (choice C) are unrelated to the test.
5. Excessive cerumen in the outer ear (choice D) does not affect proprioception.
Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.