Nokea
Which of these clients assigned to the nurse is most likely to need planning for long-term nursing management?
- A. 22-year-old with appendicitis who has had an emergency appendectomy
- B. 56-year-old with bilateral knee osteoarthritis who weighs 159 kg
- C. 34-year-old with cholecystitis who has had a laparoscopic cholecystectomy
- D. 62-year-old with acute sinusitis who will require antibiotic therapy for 5 days
Correct Answer: B
Rationale: Osteoarthritis at 159 kg screams chronic long-term PT, diet plans beat appendectomy, gallbladder, or sinus quickies. Nurses plot this, a marathon, not sprints.
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During hourly rounding the nurse enters a room where the client is unresponsive without pulse. What is the nurse's priority action?
- A. Begin ventilation at 1 breath every 6-8 seconds
- B. Start chest compressions at a rate of 100-120 compressions per minute
- C. Wait for the emergency response team for direction
- D. Call the family
Correct Answer: B
Rationale: No pulse, no response cardiac arrest kicks in chest compressions, 100-120/min, pumping life per ACLS, trumping breaths first in lone-rescuer mode. Waiting or calling delays; ventilation follows. Nurses hammer compressions, buying brain time, a priority slam in this code blue crash.
A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate?
- A. The cancer involves only the cervix.
- B. The cancer cells look like normal cells.
- C. Further testing is needed to determine the spread of the cancer.
- D. It is difficult to determine the original site of the cervical cancer.
Correct Answer: A
Rationale: Tis, N0, M0 means carcinoma in situ cancer's stuck to the cervix's surface, no invasion (T0), no lymph nodes (N0), no metastases (M0). It's early, contained. B's wrong grading, not staging, covers cell look (differentiation). C's off no spread's confirmed already. D's nonsense the cervix is the origin. Nurses break this down in oncology to ease fears only the cervix' signals a shot at cure with local treatment, not systemic chaos yet.
Which of the following should be not be routinely performed for patients with suspected non-alcoholic fatty liver disease?
- A. Liver biopsy
- B. Imaging studies like US scan
- C. Fasting lipids
- D. Fasting glucose
Correct Answer: A
Rationale: Liver biopsy, while diagnostic for NAFLD/NASH, isn't routine due to invasiveness and risks, reserved for unclear cases or staging needs, per AASLD. Ultrasound (fatty liver detection), fasting lipids, glucose, and liver function tests are non-invasive, routine screens for metabolic risk and diagnosis confirmation. This approach optimizes chronic disease evaluation safely.
The nurse is arriving at the beginning of her shift and has taken report on four clients on a medical-surgical unit. Which client should the nurse see first?
- A. A client with pain that is two days post-operative from a prostatectomy
- B. A client ready for discharge education after treatment of an acute kidney injury
- C. A client with hypertension with a blood pressure of 172/92 mm Hg
- D. A client with a history of asthma complaining of increased dyspnea
Correct Answer: D
Rationale: Asthma's increased dyspnea flags airway risk ABCs prioritize breathing, as bronchospasm could crash fast, needing nebulizers or oxygen. Post-op pain's manageable, discharge education waits, hypertension's high but stable. Nurses hit dyspnea first, ensuring airflow, a life-first call in this shift-start triage.
Which percentage of the burden of sickness in the Netherlands can approximately be avoided?
- A. 30%
- B. 40%
- C. 50%
- D. 60%
Correct Answer: B
Rationale: Dutch sickness 40% dodgeable, lifestyle tweaks cut chronic loads, not half or more. Nurses bank this, a prevention slice.