A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?

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Question 1 of 9

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?

Correct Answer: A

Rationale: The correct answer is A: Provide the patient with a writing board each shift. This intervention addresses the impaired verbal communication by offering an alternative way for the patient to communicate. Writing board enables the patient to express thoughts and feelings, reducing the risk of loneliness. Choice B doesn't directly address the communication issue. Choice C is not relevant to the nursing diagnosis. Choice D, while promoting companionship, doesn't address the specific communication concern stated in the diagnosis.

Question 2 of 9

The most significant form of meningitis is:

Correct Answer: A

Rationale: The correct answer is A: Bacterial meningitis. Bacterial meningitis is the most significant form due to its potential severity and rapid progression, requiring urgent medical intervention with antibiotics. Bacterial meningitis can lead to serious complications such as brain damage or death if left untreated. Septic meningitis (choice B) refers to meningitis caused by a systemic infection spreading to the meninges. Aseptic meningitis (choice C) is typically viral or non-bacterial in origin, usually milder than bacterial meningitis. Viral meningitis (choice D) is less severe than bacterial meningitis and often resolves on its own without specific treatment.

Question 3 of 9

A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

Correct Answer: B

Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.

Question 4 of 9

The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:

Correct Answer: C

Rationale: Rationale: 1. Insulin is a hormone produced by beta cells of the pancreas. 2. Beta cells are responsible for monitoring blood glucose levels and secreting insulin in response to high glucose levels. 3. Insulin helps regulate blood glucose by facilitating glucose uptake into cells. 4. Adenohypophysis secretes other hormones, not insulin. 5. Alpha cells of the pancreas secrete glucagon, not insulin. 6. Parafollicular cells of the thyroid secrete calcitonin, not insulin. Summary: Choice C is correct because insulin is indeed secreted from the beta cells of the pancreas. Choices A, B, and D are incorrect as they do not secrete insulin or are related to other hormones.

Question 5 of 9

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient’s care plan?

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Impaired skin integrity. This choice is correct because it directly addresses the bacterial infection in the left lower leg by focusing on the skin's condition. The patient's skin integrity is compromised due to the infection, making this nursing diagnosis appropriate. Choice A (Infection) is too broad and does not specify the impact on the skin. Choice B (Risk for infection) is incorrect because the patient already has a bacterial infection, so the risk has already manifested. Choice D (Staphylococcal leg infection) is too specific and does not address the broader issue of skin integrity. Therefore, the best choice is C as it accurately reflects the patient's current condition and guides appropriate nursing interventions to address the impaired skin integrity caused by the bacterial infection.

Question 6 of 9

After being in remission from Hodgkin’s disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin’sdisease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these finding result from:

Correct Answer: B

Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention. Incorrect options: A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain. C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion. D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.

Question 7 of 9

The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?

Correct Answer: D

Rationale: The correct answer is D. Taking piroxicam with food or an oral antacid can help reduce GI irritation as it can protect the stomach lining. Piroxicam is known to cause GI upset due to its effects on prostaglandin synthesis. Spacing the administration every 4 hours (choice A) may not necessarily prevent GI upset. Using the drug for a short time only (choice B) may not address the immediate concern of GI irritation. Decreasing the piroxicam dosage (choice C) may not be necessary if taking it with food or an antacid can effectively alleviate the GI upset.

Question 8 of 9

When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?

Correct Answer: C

Rationale: The correct answer is C: Menstrual irregularities. After a unilateral adrenalectomy, the remaining adrenal gland may be affected by spironolactone, leading to hormonal imbalances and menstrual irregularities. This drug is a potassium-sparing diuretic that can interfere with the production of aldosterone, affecting hormonal regulation. Breast tenderness (A) is not a common side effect of spironolactone. Increased facial hair (B) is associated with hirsutism, not typically seen with spironolactone. Hair loss (D) is more commonly associated with other medications like chemotherapy, not spironolactone.

Question 9 of 9

Which of the ff. actions would the nurse include in the plan of care to reduce the symptoms of the patient who has vertigo?

Correct Answer: C

Rationale: The correct answer is C: Avoid sudden movements. Vertigo is a type of dizziness where a person feels like they're spinning or the world around them is spinning. Sudden movements can worsen vertigo symptoms. By avoiding sudden movements, the nurse can help reduce the patient's vertigo symptoms. Avoiding noises (A) may help with other conditions like migraines, but it is not specifically helpful for vertigo. Encouraging fluid intake (B) is important for overall health but does not directly address vertigo symptoms. Administering analgesics (D) may help with pain but will not address the underlying cause of vertigo. Therefore, choosing option C is the most appropriate action to include in the plan of care for reducing vertigo symptoms.

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