Nokea
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
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Which of the following dietary interventions prevents the precipitation of calcium renal stones?
- A. High fiber diet
- B. Increased protein intake
- C. High fluid intake
- D. Intake of zinc
Correct Answer: C
Rationale: The correct answer is C: High fluid intake. Adequate hydration helps prevent calcium from becoming concentrated in the urine, reducing the risk of calcium stone formation. Increased fiber intake (choice A) may help prevent other types of stones but not specifically calcium stones. Increased protein intake (choice B) can actually increase calcium excretion, potentially increasing the risk of calcium stone formation. Zinc intake (choice D) does not directly impact calcium stone formation. In summary, high fluid intake is crucial for preventing the precipitation of calcium renal stones due to its role in diluting urine and preventing calcium concentration.
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
- A. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests
- B. Advanced medical interventions can cure most autoimmune disorders
- C. Autoimmune disorders include connective tissue (collagen) disorders
- D. Autoimmune disorders are distinctive, adding differential diagnosis
Correct Answer: C
Rationale: Correct Answer: C - Autoimmune disorders include connective tissue (collagen) disorders.
Rationale: Autoimmune disorders involve the immune system mistakenly attacking healthy cells and tissues in the body, which can lead to various conditions, including connective tissue disorders like rheumatoid arthritis. Providing this information to the client and family is crucial for understanding the nature of autoimmune disorders and the potential impact on the body.
Summary of other choices:
A: False-negative or false-positive serologic tests can occur in autoimmune disorders, so this statement is not specific enough to be the most appropriate information to provide.
B: Advanced medical interventions can manage symptoms but not cure autoimmune disorders, making this statement inaccurate and misleading.
D: Autoimmune disorders can present with a wide range of symptoms and can be challenging to diagnose, but this statement does not address the specific link between autoimmune disorders and connective tissue disorders.
A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
- A. Collaborative
- B. Independent
- C. Interdependent
- D. Dependent
Correct Answer: D
Rationale: The correct answer is D: Dependent. In this scenario, the nurse is administering pain medication based on a healthcare provider's prescription, which demonstrates a dependent nursing intervention. The nurse is reliant on the provider's order to carry out this action. Collaborative interventions involve working with other healthcare professionals, independent interventions are actions that nurses can initiate without supervision, and interdependent interventions involve mutual goal-setting and decision-making among healthcare team members.
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.
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
- A. Diabetic ketoacidosis
- B. Hypoglycemia
- C. Thyroid crisis
- D. Tetany
Correct Answer: C
Rationale: The correct answer is C: Thyroid crisis. These signs suggest thyroid storm, a life-threatening complication of thyroid surgery. The high fever, tachycardia, and restlessness are classic symptoms. Thyroid crisis can lead to severe complications if not managed promptly.
A: Diabetic ketoacidosis typically presents with polyuria, polydipsia, and fruity breath odor.
B: Hypoglycemia would present with symptoms like diaphoresis, tremors, and confusion.
D: Tetany is associated with hypocalcemia and presents with muscle cramps, spasms, and numbness.