Basic Nursing Care Needs of the Patient

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Which one of the following should be performed first in any patient whose injuries may include multiple closed extremity fractures?

  • A. "A thorough assessment of four limb perfusion"
  • B. "Maneuvers to prevent necrosis of the skin"
  • C. "Extremity compartment syndrome release"
  • D. "Ensuring adequate oxygenation and ventilation"
Correct Answer: D

Rationale: The correct answer is D: "Ensuring adequate oxygenation and ventilation" should be performed first in any patient with potential multiple closed extremity fractures. This is because prioritizing oxygenation and ventilation is crucial to prevent hypoxia and respiratory compromise, which can be life-threatening. Once the patient's oxygenation and ventilation are stabilized, further assessments and interventions can be performed.

A: "A thorough assessment of four limb perfusion" may be important but ensuring adequate oxygenation and ventilation takes precedence.
B: "Maneuvers to prevent necrosis of the skin" is not the immediate priority over ensuring oxygenation and ventilation.
C: "Extremity compartment syndrome release" is a critical intervention but should be performed after ensuring adequate oxygenation and ventilation.

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An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses?

  • A. Social Isolation
  • B. Impaired Adjustment
  • C. Defensive Coping
  • D. Impaired Memory
Correct Answer: A

Rationale: Incontinence can lead to withdrawal and isolation.

After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?

  • A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
  • B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
  • C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
  • D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D

Rationale: Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.

While evaluating the twelve-lead electrocardiogram tracing of your 66-year-old cardiac history patient for the possibility of an acute myocardial infarction, you note the presence of deep symmetrically inverted T waves. Which of the following is most likely the cause of this abnormal finding?

  • A. Necrosis
  • B. Ischemia
  • C. Hyperkalemia
  • D. Hypokalemia
Correct Answer: B

Rationale: Rationale: Inverted T waves are typically indicative of myocardial ischemia. Ischemia leads to altered repolarization of the ventricles, causing T wave inversions. Necrosis (choice A) would manifest as pathological Q waves rather than T wave inversions. Hyperkalemia (choice C) would cause peaked T waves, not inverted T waves. Hypokalemia (choice D) could lead to U waves or flattened T waves, but not deep symmetric T wave inversions. Therefore, choice B (Ischemia) is the most likely cause based on the presented scenario and ECG findings.

One method substance abusers use to try to hide their addiction is to

  • A. Avoid brushing their teeth
  • B. Use room fresheners
  • C. Consistently make eye contact
  • D. Have strong social relationships
Correct Answer: B

Rationale: The correct answer is B: Use room fresheners. Substance abusers may use room fresheners to mask the smell of drugs or alcohol. This can help them hide their addiction from others by creating a more pleasant environment. Avoiding brushing their teeth (A) would not effectively hide their addiction, making eye contact (C) is unrelated to hiding addiction, and having strong social relationships (D) may not necessarily conceal their substance abuse. Using room fresheners is a direct method to cover up the scent associated with substance abuse.

When transferring a resident who has a weak side,

  • A. The weaker side moves first
  • B. The stronger side moves first
  • C. The strong side and weak side move at the same time
  • D. It does not matter which side moves first
Correct Answer: B

Rationale: The correct answer is B because when transferring a resident with a weak side, it is safer to have the stronger side move first to provide better support and stability. This helps prevent falls and injuries by ensuring the resident's weight is predominantly supported by the stronger side. Moving the weaker side first may increase the risk of imbalance and potential harm. Choice A is correct because it prioritizes safety and proper weight distribution. Choices C and D are incorrect as they do not address the importance of supporting the resident effectively during transfers, which is crucial for their well-being.