Nokea
Whoch of the ff. is a desired outcome for the nursing diagnosis of acute pain for a patient with acute thrombophlebitis?
- A. States anxiety is decreased
- B. States pain is satisfactorily relieved c.Is able to participate in desired activities
- C. Reports ability to ambulate without pain
Correct Answer: C
Rationale: A desired outcome for the nursing diagnosis of acute pain related to acute thrombophlebitis would be for the patient to be able to participate in desired activities. By achieving pain relief and being able to engage in activities they enjoy or find important, the patient's overall quality of life can be improved. This outcome focuses on enhancing the patient's ability to function and maintain independence despite the pain associated with the thrombophlebitis. It reflects a holistic approach to care that considers the patient's physical, emotional, and social well-being. Ultimately, the goal is to help the patient achieve a level of comfort and mobility that allows them to resume their desired activities.
You may also like to solve these questions
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
- A. Massage reddened areas with lotion or oils
- B. Use special water mattress
- C. Turn frequently every 2 hours
- D. Keep skin clean and dry
Correct Answer: C
Rationale: Turning the patient frequently every 2 hours helps relieve pressure on specific areas of the body, hence reducing the risk of developing decubitus ulcers. Prolonged pressure on the skin can lead to poor blood circulation and tissue damage, which can eventually progress into decubitus ulcers. By turning the patient regularly, the pressure is redistributed and different areas of the skin are relieved from constant stress. This simple measure is an effective way to prevent the occurrence of decubitus ulcers in patients on prolonged bed rest.
Which of the following statements is true regarding Joel's disorder? a.Hemophilia is an autosomal dominant disorder in which the woman carries the trait
- A. Hemophilia follows regular laws of Mendelian inherited disorders such as sickle ceil anemia
- B. This disorder can be carried by either male or female but occurs in the sex opposite that of the carrier
- C. Hemophilia is an X-linked disorder in which the mother is usually the carrier of the illness but is not affected by it
Correct Answer: C
Rationale: Hemophilia is an X-linked disorder, meaning the gene responsible for hemophilia is carried on the X chromosome. Typically, hemophilia is passed down from a carrier mother to her male offspring who then express the disorder. This is because males have only one X chromosome (inherited from their mother), making them more vulnerable to X-linked disorders. Females have two X chromosomes, which means that even if one carries the hemophilia gene, the other X chromosome may carry a normal gene that can compensate, making females less likely to exhibit symptoms of hemophilia. In this case, Joel's disorder aligns with the typical pattern of inheritance for hemophilia as described in statement C.
A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
- A. Wash the area with soap and warm water
- B. Leave the skin alone until it is clear
- C. Apply a cream or lotion to the area
- D. Avoid applying creams or lotion to the area
Correct Answer: C
Rationale: Radio-dermatitis is a common side effect of radiation therapy, characterized by inflammation and irritation of the skin. Applying a cream or lotion to the affected area can help soothe the skin, reduce inflammation, and provide relief from symptoms such as itching and discomfort. It is important to choose a cream or lotion that is specifically designed for sensitive skin and recommended by healthcare professionals to ensure effectiveness and safety in managing radio-dermatitis. Washing the area with soap and warm water may further irritate the skin, while leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions may lead to dryness and further discomfort.
While assessing a newborn infant for developmental hip dysplasia (DDH), the nurse evaluates which of the following signs as indicating the presence of DDH?
- A. One knee is lower when both legs are flexed
- B. Thigh and gluteal skin folds are symmetrical
- C. Hip adduction of affected side is limited
- D. Negative Ortolani sign when hips are abducted
Correct Answer: A
Rationale: In developmental hip dysplasia (DDH), one knee appearing lower than the other when both legs are flexed indicates a possible dislocated hip joint or hip dysplasia. This finding is known as the Galeazzi sign and is often used as a clinical indicator for DDH in newborn infants. It suggests a discrepancy in leg lengths due to hip instability or malformation. Therefore, this sign is important in helping to diagnose DDH and initiating appropriate interventions early on.
A seizure characterized by loss of consciousness and tonic spasms of the trunk and extremities rapidly followed by repetitive generalized clonic jerking is classified as:
- A. Focal seizure
- B. Jacksonian seizure
- C. Generalized seizure
- D. Partial seizure
Correct Answer: C
Rationale: The description provided aligns with the characteristics of a generalized seizure. Generalized seizures involve abnormal electrical activity in the entire brain, leading to loss of consciousness and widespread motor symptoms, such as tonic (stiffening) and clonic (jerking) movements affecting both sides of the body. Examples of generalized seizures include tonic-clonic seizures (formerly known as grand mal seizures) where there is a sequence of tonic stiffness followed by clonic jerking. In contrast, focal (partial) seizures originate in a specific area of the brain and may result in localized symptoms before possibly spreading to involve both sides of the brain. Jacksonian seizures specifically refer to focal seizures with motor symptoms that spread in a stepwise fashion, starting from one part of the body.