Steven, an athletic 20-year-old college student, suffered a fractured shoulder and sprained wrist in a fall at a ski resort.
In developing Steven's care plan following surgery, which of the following typical problems would you anticipate?
A. He will undergo an alteration in self-concept.
B. He will experience anxiety as a result of flashbacks about the skiing accident.
C. He will have impaired mobility caused by immobilization of upper extremity.
D. There will be abnormal tissue perfusion caused by swelling.
If you use both the information provided and your understanding of surgical needs following reduction of a fracture, the only problem that would normally occur is impaired mobility. In analyzing data you would first attempt to recall and understand typical scenarios or patterns of needs that commonly occur. Validate your problem definition by incorporating specialized data or individualized signs and symptoms presented by your client. These specialized data should be accompanied by a statement of cause. For example, if you note that Steven's fingertips are cold and pitting edema is forming on the back of the hand, your analytic statement might be option D, abnormal tissue perfusion caused by swelling. An accurate analysis of data provides a valid and useful framework for planning patient care.
Jean Thomas is a 25-year-old secretary admitted to the emergency room with diaphoresis, hyperventilation, palpitations, and trembling. Jean tells the nurse that she has been "very upset and nervous" over a poor employment evaluation. A tentative diagnosis of acute anxiety episode is made.
Which of the following acid-base imbalances would likely occur as a result of Jean's hyperventilation?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
The intended response is B, since hyperventilation will cause an increased loss of CO2,
Mrs. Durham is recovering from a colon resection for removal of a malignant mass in the large bowel. Following breakfast one morning, she told the nurse, "I'm tired of waiting, I want my bath now. You're never here when I need you."
- Which of the following responses by the nurse is most appropriate?
A. What do you mean, I'm never here? I spent all three hours with you yesterday, Mrs. Durham.
B. I'm sorry you've been waiting Mrs. Durham. Let's get you comfortable now and I'll be back in twenty minutes to give you a bath.
C. I'm doing my best, Mrs. Durham. You know I have three other patients to take care of today, besides you.
D. I must see Mrs. Jones right now, Mrs. Durham. She's really sick today. I'll be back as soon as I can.
The only appropriate response is option B. Acknowledge her feelings and give her a clear, factual response to her concern. Never challenge a patient's statements and don't be defensive (option C). Do not reprimand the patient unnecessarily or talk about the needs of the other patients ( options C and D). In this case you did not need to know a lot about colon resections to answer this question. You did need to have skill in basic communication and human interaction.
Brian, aged 4 years, is sitting in the pediatric day room with Michael, another patient. He suddenly realizes that he has wet his pants and runs to the nurse, crying.
The most appropriate initial response by the nurse is:
A. Why, Brian, what happened? Why did you wet your pants?
B. You know better than this, Brian; next time you'll get a good spanking.
C. Let's take off those wet pants, Brian, and put on something dry so you'll be more comfortable.
D. Wait until I tell Michael what you did. Aren't you ashamed of yourself?
Several relevant principles come into play in this item in selecting the correct answer. A very basic principle is, "The nurse shows respect for the individual in treating human responses to actual or potential health problems." In other words, focus on treating the patient with respect first and then attempt to modify wrong behavior. This principle shows an acceptable standard of nursing action. The intended response is C.
Margaret O'Hara, a 30-year-old known diabetic, is brought to the emergency department by ambulance. The paramedic team reports symptoms of apparent hyperglycemia. Stat blood glucose is 640.
The nurse is aware that excess serum glucose acts to draw fluids osmotically with resultant polyuria. In addition to increased urinary output, the nurse should expect to observe which of the following sets of symptoms in Margaret?
A. Polydipsia, diaphoresis, bradycardia
B. Thirst, dry mucous membranes, hot dry skin
C. Hypotension, bounding pulse, headache
D. Nervousness, rapid respirations, diarrhea
The intended response is B, because these are all symptoms associated with the dehydration that occurs in hyperglycemia. Although polydypsia is expected (response A), diaphoresis does not occur in the body's effort to compensate by holding back fluid. The patient would experience tachycardia as a cardiac compensatory mechanism, causing a rapid, thready pulse. Headache and nervousness (responses C and D) are symptoms associated with hypoglycemia.
Molly Flannery is a 67-year-old female with chronic congestive heart failure and hypertension. She is being evaluated for complaints of muscular weakness and general fatigue.
Molly's serum electrolyte studies reveal a K+ level of 2.9. Which of the following medications taken by the patient at home contributed most to her hypokalemic state?
A. Digoxin, .125 mg, PO, daily
B. Lasix, 80 mg, PO, daily
C. Aldomet, 250 mg, PO, tid
D. Aspirin, 10 grains, bid
The intended response is B, since Lasix, in addition to its diuretic action, also wastes K+ by increasing urinary excretion. Digoxin, response A, contributes to K+ loss by enhancing urinary output, but Lasix is much more directly related to the development of hypokalemia. Response C is an anti-hypertensive that is not related to K+ loss. Response D, aspirin, may have been prescribed as myocardial infarction prophylaxis, and is not related to K+ loss.
Mr. Robert Bacchus is a 63-year-old retired business executive who comes to the emergency room with complaints of dyspnea, shortness of breath, and chest pain radiating to the left arm.
The nurse caring for Mr. Bacchus should implement which of the following actions FIRST?
A. Administer prescribed pain medication
B.. Apply oxygen per nasal cannula as ordered
C. Assess vital signs
D. Apply electrocardiogram electrodes to the patient's chest
The intended response is C, since vital sign assessment will provide baseline data of vital cardiac and respiratory function, which will then serve as a guideline for diagnosis and therapy measures.
Loberta Jackson, a 21-year-old college student, is admitted to a medical unit with diagnosis of uncontrolled diabetes, acute hypoglycemic reaction.
Loberta explains to the admitting nurse that she had been feeling "sick to my stomach, like I was coming down with the flu" for the past 48 hours. She has continued to take her usual daily dosage of insulin. Noting that Loberta has been admitted with a blood-glucose value of 46, which of the following assessment questions would provide the most valuable information about Loberta's status?
A.. "Have you been under a great deal of stress lately, Loberta?"
B. "Were you having difficulty sleeping after this illness started?"
C. "Have you eaten anything in the past 48 hours?"
D. "Did you take any medications for this illness other than your insulin?"
The intended response is C, because it is highly probable that Loberta, feeling "sick to her stomach," has not taken in adequate foods and fluids, and coupled with taking her usual dosage of daily insulin, has brought about an acute hypoglycemic reaction. (Higher than normal circulating levels of insulin with insufficient food intake of essential nutrients will result in acute decreased blood-glucose levels). Response A, focusing on increased stress, would more than likely stimulate a hyperglycemic reaction, since stress causes elevations of blood glucose. Response D, focusing on other medications the patient has taken, would probably not trigger a hypoglycemic reaction. Response B is unrelated to her present status.
Jerry is a 32-year-old white male. He has been married for 10 months, and he and his wife, Sue, are expecting their first child in 6 months. Prior to marrying Sue, Jerry was sexually active and nonmonogamous. He has been sexually active since the age of 18. Recently Jerry has complained of persistent dry cough, night sweats, and a temperature over 100?F. Although Jerry is concerned about his weight and watches his diet, he has lost 15 pounds without even trying. Upon assessing Jerry, he admits to having had sexual intercourse with prostitutes, both male and female, during the last 10 years.
Jerry's symptoms of elevated temperature, chills, and dry cough are probably related to which undiagnosed condition?
A. Alteration in tissue perfusion
B. An infection, etiology unknown
C. Indigestion from too frequent traveling
D. Lack of knowledge related to frequent travel
The intended response is B. Classic signs and symptoms of infection are fever, chills, loss of appetite, generalized myalgias, or localized pain and discomfort. The dry cough that Jerry experiences can be associated with the system of involvement. Pulmonary etiology should be assessed and evaluated.
Mrs. Brown's husband was admitted to the emergency room in delirium tremens (DTs). This admission is his third visit in 2 weeks. While waiting to see her husband, Mrs. Brown said to the nurse, "What in the world can I do to help Joe get over this drinking problem?"
The best initial response for the nurse is:
A. Don't feel guilty, Mrs. Brown; I know this must be difficult for you.
B. Let's go into the lounge so we can talk more about your concern, Mrs. Brown.
C. You need to convince Joe to seek professional help, Mrs. Brown.
D. How long has your husband been drinking, Mrs. Brown?
If you chose Option A, you are reading into the question and adding a factor that was not provided-- that Mrs. Brown is feeling guilty. Perhaps you know of someone who did feel guilty in a situation like this, or perhaps you thought she should feel guilty. Because this background statement does not tell you how Mrs. Brown feels, you can't make this assumption (option A).
Option C is incorrect because you don't have enough information about the situation to offer this advice. You should be in the assessment or data collection phase of the nursing process. Option D is not the best choice because it focuses on Mr. Brown's problem and channels the interaction specifically, rather than encouraging Mrs. Brown to express her concerns. Since Mrs. Brown is concerned about what she can do to help her husband, the correct response is one that first encourages her to verbalize how she is feeling (option B).
Amy Stevens is a 17-year-old student admitted for evaluation of lower abdominal pain. She tells the nurse, "I wish my friends would come to visit me. I don't like being here alone."
Which of the following would be the most appropriate response of the nurse?
A. "You sound very lonely. Shall I stay with your for awhile?"
B. "I'm sure your friends will come to see you soon."
C. "It's a little too early for visiting hours. You'll have to wait until this afternoon."
D. "It's hard to be alone. Would you like me to stay with you?"
The intended response is D, since this response acknowledges the patient's feelings and offers support. Response A tends to catastrophize the patient's situation by saying "you must be very lonely." Response B provides false reassurance because the nurse has no real way of knowing if in fact friends will come to visit Amy. Finally, C is incorrect because it provides only a factual response and does not attend to the feeling tone of Amy's remarks.
Patty Daniels is a 25-year-old white female, pregnant with her first child. She is being seen in the obstetrical clinic for her first prenatal visit.
Patty tells the nurse, "I drank a glass of wine at a party before I found out that I was pregnant. I'm worried that I might have hurt the baby." Based on an understanding of alcohol use in pregnancy, which of the following responses is the most appropriate?
A. "We don't really know how much alcohol is too much during pregnancy. Don't drink anymore and try not to worry about it."
B. "As long as your drinking is moderate, I wouldn't worry about it. There were plenty of healthy babies born to drinking mothers before they ever discovered fetal alcohol syndrome."
C. "An occasional drink shouldn't hurt the baby. Research has shown that the risk to the fetus increases as the amount and frequency of alcohol consumption increases."
D. "I can understand why you're so upset, but an occasional drink shouldn't hurt the baby."
The correct response is C. This patient needs two things from the nurse: information about alcohol use in pregnancy and reassurance about the potential risk to her own baby. Alcohol is a known teratogenic substance, but it is unclear how much alcohol it takes and at what point in development to adversely affect the fetus. Research has shown that the incidence of fetal alcohol syndrome and related disorders increases as the amount and frequency of alcohol consumption increase. An occasional drink should not harm the fetus. C is the correct response because it is the only answer that offers reassurance and accurate information without catastrophizing the situation.
Kelly Jones, aged 3 years, is brought to the emergency room by her mother following an accidental ingestion of acetaminophen. When questioned, Mrs. Jones states that she believes that Kelly ingested approximately 20 tablets. She further states that she believes that the ingestion occurred within the last hour.
Immediately upon arrival in the emergency room the nurse should:
A. Assess vital signs
B. Administer O2
C. Start IV fluids
D. Perform an arterial puncture for blood gases
A is the correct response. The establishment of baseline vital signs should always be done first. Although hyperventilation and resultant respiratory alkalosis is the most obvious clinical manifestation, acetaminophen does not exert its peak effect until 2 to 4 hours following ingestion. Performing an arterial puncture for blood-gas analysis will be important, but it is not the first thing that the nurse should do. There is no indication at this time for the administration of O2 or IV fluids.