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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.
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Beta-adrenergic agonists such as albuterol are given to Reggie, a child with asthma. Such drugs are administered primarily to do which of the following?
- A. Dilate the bronchioles
- B. Reduce secondary infections
- C. Decrease postnasal drip
- D. Reduce airway inflammation
Correct Answer: A
Rationale: Beta-adrenergic agonists like albuterol primarily work by relaxing and dilating the bronchioles, which are the smaller airways in the lungs. This leads to quick relief of asthma symptoms such as wheezing, shortness of breath, and chest tightness. By opening up the airways, these medications help improve airflow and make it easier for the individual to breathe. Beta-adrenergic agonists do not directly reduce airway inflammation, but they do provide immediate relief during an asthma attack by targeting bronchoconstriction.
The patient is being discharged on furosemide (Lasix). The nurse evaluates the patient as understanding her medication teaching if she states that she will have which of the ff. laboratory tests monitored as ordered?
- A. "I will have my urine sodium checked."
- B. "I will have my prothrombin time checked."
- C. "I will have my calcium level checked."
- D. "I will have my potassium level checked."
Correct Answer: D
Rationale: Furosemide (Lasix) is a loop diuretic that works by increasing the excretion of water and electrolytes such as sodium, chloride, and potassium in the urine. One of the most common side effects of furosemide is hypokalemia, or low potassium levels. Monitoring potassium levels is crucial while taking furosemide to prevent complications such as muscle weakness, cardiac arrhythmias, and other electrolyte imbalances. Therefore, the patient should have her potassium level checked as ordered to ensure her safety and effectiveness of treatment.
The parents of a young child with heart failure tell the nurse that they are "nervous" about giving digoxin (Lanoxin). The nurse's response should be based on which statement?
- A. It is a safe, frequently used drug.
- B. It is difficult to either overmedicate or undermedicate with digoxin.
- C. Parents lack the expertise necessary to administer digoxin.
- D. Parents must learn specific, important guidelines for administration of digoxin.
Correct Answer: A
Rationale: The correct response is option A. By reassuring the parents that digoxin is a safe and frequently used drug, the nurse can help alleviate their concerns about administering the medication to their child. This approach fosters trust and confidence in the treatment plan. It is essential for the nurse to provide accurate information to help the parents feel more comfortable and confident in caring for their child.
A 3-year-old boy is hospitalized after falling down the stairs. His mother cries, 'This is all my fault.' Which is the nurse's best response?
- A. Accidents happen; you shouldn't blame yourself.
- B. Falls are one of the most common injuries in this age group.
- C. It might help to install a baby gate on the stairs.
- D. Your son should be proficient at walking down stairs by now.
Correct Answer: B
Rationale: Reassuring the parent that falls are common in young children can help reduce guilt and anxiety.
A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the nurse, "Wait a minute" and "I'm not ready." The nurse should recognize this as which description?
- A. This is normal behavior for a school-age child.
- B. The behavior is not seen past the preschool years.
- C. The child thinks the nurse is punishing her.
- D. The child has successfully manipulated the nurse in the past.
Correct Answer: A
Rationale: This is normal behavior for a school-age child. School-age children often assert their independence and control in various situations, such as medical procedures. It is common for children in this age group to express hesitation or resistance when faced with something uncomfortable or unfamiliar, like starting an IV line. The child's behavior of saying "Wait a minute" and "I'm not ready" is a typical response for a 10-year-old girl and does not necessarily indicate manipulation, punishment perception, or behavior typical of younger children. In this case, the nurse should acknowledge the child's feelings, provide reassurance, and offer explanations to help her feel more comfortable and in control of the situation.