Nokea
You are the nurse in an ambulatory surgical center. Which of the following risk factors are associated with impaired and delayed healing?
- A. A lack of zinc
- B. A lack of vitamin E
- C. High iron levels
- D. High phosphorus levels
Correct Answer: A
Rationale: Zinc deficiency impairs wound healing by affecting collagen synthesis and immune function.
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A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation should the nurse assess the client for?
- A. Bilateral palpable masses
- B. Pain in the breast and edema
- C. A fixed, irregularly shaped mass
- D. A round-shaped mass that is moveable
Correct Answer: C
Rationale: Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregularly shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.
A female client with paranoid schizophrenia has been hearing negative voices and 'getting special messages from various sources,' which of the following interventions is most appropriate for the client's symptoms?
- A. Asking her to make simple decisions
- B. Being matter-of-fact with her
- C. Monitoring her reactions to television programs
- D. Reinforcing appropriate dress and hygiene
Correct Answer: B
Rationale: Being matter-of-fact helps ground a client with paranoid schizophrenia, reducing misinterpretations of reality. Decision-making, TV monitoring, or hygiene reinforcement are less directly related to auditory hallucinations.
A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the discharge plan, the nurse should include information about:
- A. Allowing the child to lead a normal, active life.
- B. Persuading the child to get enough rest.
- C. Having the child develop postoperative complications.
- D. Having the child out of school for a month.
Correct Answer: A
Rationale: After tetralogy of Fallot repair, children can often lead a normal, active life with appropriate follow-up.
A client with a history of atrial fibrillation is admitted with a heart rate of 160 beats per minute. The nurse should prioritize which of the following interventions?
- A. Administer diltiazem as prescribed.
- B. Obtain a 12-lead ECG.
- C. Administer aspirin.
- D. Apply oxygen via nasal cannula.
Correct Answer: A
Rationale: Diltiazem, a calcium channel blocker, is prioritized to control rapid heart rate in atrial fibrillation.
The Patient Self Determination Act of the United States protects clients in terms of their rights to what? Select all that apply.
- A. Privacy and to have their medical information confidential unless the client formally approves the sharing of this information with others such as family members.
- B. Make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so.
- C. Be fully informed about all treatments in term of their benefits, risks and alternatives to them so the client can make a knowledgeable and informed decision about whether or not to agree to having it
- D. Make decisions about who their health care provider is without any coercion or undue influence of others including healthcare providers.
Correct Answer: B,C
Rationale: The Patient Self Determination Act (PSDA) of 1990 ensures that patients are informed of their rights to make decisions about their healthcare, including the right to accept or refuse treatment and to formulate advance directives . It also requires that patients be informed about treatment options, risks, benefits, and alternatives to make informed decisions . Option A relates to HIPAA, not the PSDA, and option D is not a specific right protected under the PSDA.