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While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.
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The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.” DISTURBANCES IN IMMUNOLOGIC FUNCTIONING
Correct Answer: E
Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?
During the evaluation phase, what key action does the nurse perform?
- A. Diagnose the client’s condition based on new information.
- B. Identify nursing interventions for client care.
- C. Determine the effectiveness of the care plan.
- D. Develop goals and outcomes for client care.
Correct Answer: C
Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately.
Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.
If a client’s parathyroid glands were accidentally removed during a procedure, which condition should the nurse prepare for?
- A. Hypomagnesemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypocalcemia
Correct Answer: D
Rationale: The correct answer is D: Hypocalcemia. The parathyroid glands regulate calcium levels in the body. Without them, calcium levels will drop, leading to hypocalcemia. A: Hypomagnesemia is incorrect because magnesium levels are not directly regulated by the parathyroid glands. B: Hyperkalemia and C: Hypernatremia are incorrect as they are not typically associated with parathyroid gland removal. In summary, the removal of parathyroid glands would result in hypocalcemia due to the disruption of calcium regulation in the body.
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
- A. Radiation therapy
- B. Chemotherapy
- C. Major surgery
- D. None
Correct Answer: C
Rationale: The correct initial treatment for stage IV ovarian cancer is major surgery (Choice C). This is because at this advanced stage, surgery is typically performed to debulk the tumor and remove as much cancerous tissue as possible, followed by chemotherapy to target any remaining cancer cells. Radiation therapy (Choice A) is not typically the initial treatment for ovarian cancer. Chemotherapy (Choice B) is often used in combination with surgery, but surgery is usually the first line of treatment for stage IV disease. Choosing no treatment (Choice D) would be detrimental as the cancer is advanced and requires immediate intervention.
What is the causative agent in HIV/AIDS?
- A. trichomonas vaginalis
- B. Treponema pallidum
- C. Human, T-cell lymphotrophio virus
- D. Chlamydia tranchomatis
Correct Answer: C
Rationale: The correct answer is C: Human, T-cell lymphotrophic virus, as it is the causative agent for HIV/AIDS. This virus specifically targets and infects the body's T-cells, weakening the immune system. Trichomonas vaginalis, Treponema pallidum, and Chlamydia trachomatis are all different pathogens that do not cause HIV/AIDS. Trichomonas vaginalis is a protozoan parasite that causes trichomoniasis, Treponema pallidum causes syphilis, and Chlamydia trachomatis causes chlamydia. Therefore, the correct answer is C based on the specific viral agent responsible for HIV/AIDS.