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Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
- A. "I think you should ask the doctor. Would you like me to cail him for you?"
- B. " The blood supply to the brain has decreased causing permanent brain damage."
- C. "It Is a temporary interruption in the blood flow to the brain."
- D. "TIA means a transient ischemic attack."
Correct Answer: C
Rationale: The correct answer is C: "It is a temporary interruption in the blood flow to the brain." This response is correct because it accurately describes a transient ischemic attack (TIA) as a temporary condition where blood flow to the brain is briefly interrupted. This explanation is clear, concise, and provides the family member with an accurate understanding of TIA.
Choice A is incorrect because it deflects the question and suggests involving the doctor unnecessarily. Choice B is incorrect as it inaccurately states that TIA causes permanent brain damage, which is not true. Choice D is incorrect as it simply defines the acronym without providing any meaningful information about what TIA actually is.
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A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?
- A. Adrenal cortex
- B. Adrenal medulla
- C. Pancreas
- D. none of the above
Correct Answer: A
Rationale: The correct answer is A: Adrenal cortex. Primary hyperaldosteronism is a condition where the adrenal cortex produces too much aldosterone hormone, leading to hypertension. The adrenal medulla secretes adrenaline and noradrenaline, not aldosterone, making option B incorrect. The pancreas secretes insulin and glucagon, not aldosterone, making option C incorrect. Option D is incorrect because the adrenal cortex is responsible for aldosterone secretion in primary hyperaldosteronism.
A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient’s plan of care?
- A. Determine whether the patient has transportation to get home.
- B. Evaluate whether patient goals and outcomes have been met.
- C. Establish whether the patient has a follow-up appointment scheduled.
- D. Ensure that the patient’s prescriptions have been filled to take home. NursingStoreRN
Correct Answer: B
Rationale: The correct answer is B because before discontinuing a patient's plan of care related to physical mobility, the nurse needs to evaluate whether the patient goals and outcomes have been met. This step ensures that the patient has achieved the desired level of physical mobility improvement and is ready to safely continue their care at home.
A: Determining whether the patient has transportation to get home is important but not directly related to the patient's physical mobility goals and outcomes.
C: Establishing a follow-up appointment is important but does not directly address the evaluation of the patient's physical mobility improvement.
D: Ensuring that the patient's prescriptions are filled is crucial for medication management but does not specifically evaluate the patient's physical mobility progress.
A patient reports on admission being “very sick” after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?
- A. Give the antibiotic
- B. Do not give the antibiotic
- C. Give half of the dose
- D. Discontinue the antibiotic
Correct Answer: B
Rationale: The correct answer is B: Do not give the antibiotic. This is because the patient has a history of being "very sick" after taking erythromycin in the past, indicating a potential allergic reaction or severe adverse effects. The nurse should not administer the antibiotic to prevent harm to the patient. Choice A is incorrect as it can lead to a repeat adverse reaction. Choice C, giving half the dose, still exposes the patient to potential harm. Choice D, discontinuing the antibiotic, is also incorrect as it implies the patient has already started the medication, which should not be the case given the history of adverse effects.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition.
Incorrect choices:
A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it.
B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed.
D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis of Readiness for enhanced urinary elimination, which indicates the patient's willingness to improve their urinary elimination abilities. Health promotion diagnoses focus on improving the client's well-being and enhancing their health potential. In this scenario, the patient's desire to learn self-catheterization aligns with health promotion as it involves empowering the patient to take an active role in their care.
Choice A (Risk) is incorrect because the patient is not currently at risk for urinary elimination issues, but rather seeking to enhance their abilities. Choice B (Problem focused) is incorrect as the diagnosis is not about addressing a current problem but rather focusing on potential improvement. Choice D (Collaborative problem) is incorrect as it does not involve collaboration between healthcare providers but rather focuses on the patient's readiness and willingness to enhance their own health outcomes.