Nokea
Which of the following statements does NOT apply to a nursing plan of care?
- A. It contains short-term goals
- B. It is developed by the patient's physician
- C. It must be continually evaluated
- D. It contains long-range goals
Correct Answer: B
Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.
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Which of the following statements does NOT apply to a nursing plan of care?
- A. It contains short-term goals
- B. It is developed by the patient's physician
- C. It must be continually evaluated
- D. It contains long-range goals
Correct Answer: B
Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.
Which of the following is a potential side effect associated with the use of nonsteroidal anti-inflammatory drugs?
- A. Stomach irritation and bleeding
- B. Stomatitis and esophagitis
- C. Impaired folate absorption
- D. Increased potassium excretion
Correct Answer: A
Rationale: The correct answer is A: Stomach irritation and bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause stomach irritation and bleeding due to their effects on gastric mucosa. Stomatitis and esophagitis (Choice B) are not typically associated with NSAID use. While NSAIDs may affect renal function, leading to fluid retention and edema, they do not directly cause increased potassium excretion (Choice D). Impaired folate absorption (Choice C) is not a common side effect of NSAIDs.
The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?
- A. Discontinue the use of steroid therapy immediately if symptoms develop.
- B. Take diuretics as needed to treat the dependent edema in ankles.
- C. Increase the intake of dietary sodium every day to decrease fluid retention.
- D. Report any decrease in daily weight during treatment to the healthcare provider.
Correct Answer: D
Rationale: The correct answer is D. Reporting a decrease in daily weight is crucial when managing nephritic syndrome as it can indicate worsening of the condition or dehydration. It is essential to monitor weight changes closely to assess the effectiveness of treatment and the client's fluid status. Choice A is incorrect because discontinuing steroid therapy abruptly can lead to complications; gradual tapering is usually recommended. Choice B is incorrect as diuretics should be taken as prescribed by the healthcare provider to manage fluid retention. Choice C is also incorrect because increasing dietary sodium can exacerbate fluid retention, which is counterproductive in nephritic syndrome.
The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?
- A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
- B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
- C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
- D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress
Correct Answer: C
Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.
Participating in the development of long-term and preventive health goals with the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: B
Rationale: The correct answer is B: Planning. Planning in nursing care involves setting long-term and preventive goals for the patient in collaboration with the patient and their family. This step ensures that a comprehensive and individualized care plan is developed. Choice A, Evaluation, comes after the interventions have been implemented to assess their effectiveness. Choice C, Implementation, is the step where the care plan is put into action. Choice D, Assessment, is the initial step that involves collecting data to identify the patient's needs, which is done before planning the care.