The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?

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Question 1 of 9

The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?

Correct Answer: C

Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.

Question 2 of 9

After contributing to the care of several patients who died in the hospital, the nurse has identified some lapses in the care that many of these patients received toward the end of their lives. What have research studies identified as a potential deficiency in the care of the dying in hospital settings?

Correct Answer: A

Rationale: The correct answer is A. Research studies have consistently shown that families' needs for information and support often go unmet in hospital settings when caring for dying patients. This is a crucial deficiency as effective communication and support for families can greatly impact the quality of care provided to the dying patient. When families are not adequately informed and supported, it can lead to increased stress, confusion, and dissatisfaction with the care provided. Choices B, C, and D are incorrect because they do not address the specific deficiency identified in research studies. While pain control, communication, and attention from caregivers are important aspects of end-of-life care, the primary focus in this scenario is on the unmet needs of families for information and support. Ignoring families' needs can have significant negative consequences on the overall care provided to the dying patient.

Question 3 of 9

A nurse is providing care to a patient with anindwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)?

Correct Answer: A

Rationale: The correct answer is A: Drapes the urinary drainage tubing with no dependent loops. This practice helps prevent CAUTI by ensuring that urine does not flow back into the bladder, reducing the risk of infection. Dependent loops can lead to stagnant urine, providing a breeding ground for bacteria. Choice B is incorrect because washing the drainage tube towards the meatus can introduce bacteria into the urinary tract, increasing the risk of infection. Choice C is incorrect because placing the drainage bag on the floor can introduce contaminants from the floor into the system. Choice D is incorrect because allowing the spigot to touch the receptacle can lead to contamination and increase the risk of infection.

Question 4 of 9

A nurse is developing a plan to reduce data entryerrors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

Correct Answer: B

Rationale: The correct answer is B: Implement an automatic sign-off. This guideline helps reduce data entry errors by ensuring that all entries are completed and saved before exiting the system, thus maintaining confidentiality. Bypassing the firewall (A) would compromise data security. Creating a password with just letters (C) may not be secure enough. Using a programmed speed-dial key when faxing (D) is unrelated to reducing data entry errors or maintaining confidentiality.

Question 5 of 9

A patient is experiencing oliguria. Which actionshould the nurse performfirst?

Correct Answer: A

Rationale: The correct answer is A: Assess for bladder distention. Oliguria indicates decreased urine output, which could be due to urinary retention. Assessing for bladder distention helps identify the underlying cause. Requesting diuretics (B) without assessing first is premature. Increasing IV fluid rate (C) may worsen the situation if there is urinary retention. Encouraging caffeinated beverages (D) is not appropriate as they can worsen dehydration.

Question 6 of 9

A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patients care?

Correct Answer: D

Rationale: The correct answer is D: Surgical intervention. Cataracts are a clouding of the lens in the eye, which can lead to vision impairment. Surgery is the most common and effective treatment for cataracts, involving the removal of the cloudy lens and replacement with an artificial one. Antioxidant supplements (Choice A) may help prevent cataracts but are not a treatment for existing ones. Eyeglasses or magnifying lenses (Choice B) can help with vision correction but do not address the cataracts themselves. Corticosteroid eye drops (Choice C) are used for treating inflammation in the eye, not cataracts. Therefore, surgical intervention is the most appropriate treatment option for age-related cataracts.

Question 7 of 9

A nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include?

Correct Answer: A

Rationale: The correct answer is A because referenced daily intakes (RDIs) provide values for protein, vitamins, and minerals essential for maintaining health. RDIs do not focus solely on fat, cholesterol, and fiber percentages (B). RDIs are different from recommended daily allowances (RDAs) but do not replace them (C). RDIs are not specifically used to develop diets for chronic illnesses requiring a specific calorie intake (D).

Question 8 of 9

The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan?

Correct Answer: D

Rationale: The correct answer is D: Risk for Self-Care Deficit Related to Skin Lesions. Patients with atopic dermatitis may experience difficulty performing self-care tasks due to pain, itching, and limitations in hand mobility caused by skin lesions. This diagnosis addresses the potential challenges the patient may face in maintaining personal hygiene and managing their skin condition. Explanation for why other choices are incorrect: A: Risk for Disturbed Body Image Related to Skin Lesions - While atopic dermatitis may impact body image, the priority in this case is the patient's ability to perform self-care. B: Risk for Disuse Syndrome Related to Dermatitis - Disuse syndrome is not typically associated with atopic dermatitis. C: Risk for Ineffective Role Performance Related to Dermatitis - This diagnosis focuses on the patient's ability to fulfill their roles, which may not be directly impacted by atopic dermatitis.

Question 9 of 9

A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?

Correct Answer: A

Rationale: Step 1: The nurse is auditing and monitoring patients' health records, indicating a review process. Step 2: By reviewing patients' health records, the nurse is determining the degree to which standards of care are met. Step 3: This action aligns with auditing, which involves assessing if care meets established standards. Step 4: The other choices are incorrect because they do not directly involve auditing or monitoring for compliance with standards of care. Choice B talks about undocumented care, C about reimbursement, and D about treatment outcomes comparison.

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