Tiêu đề DIAGNOSTIC EXAMINATION - NP3 - ANSWER KEY ✅

severe hypertension C. Will displace the location of the tumor D. Will cause sudden release of epinephrine and severe palpitation Situation 9 – Janine is the Nurse on duty in the medical ward and many of her patients are suffering from problems of oxygenation. 56. The following are relevant data to be documented when taking the health history of a client with anemia EXCEPT: A. Alcohol intake – an accurate history of alcohol intake, including the amount and duration, should be obtained (Brunner &Suddarth, p.879) B. Fatigue and weakness – weakness, fatigue & general malaise are common symptoms for patients with anemia (Brunner &Suddarth, p.879); this is assessed as part of Gordon’s functional health patterns (activity-exercise pattern) C. Dietary intake – a nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folic acid (Brunner &Suddarth, p.879) D. Episodes of bleeding – anemia is a condition in which the haemoglobin concentration is lower than normal (presence of fewer than normal RBCs within the circulation), which results to diminished amount of oxygen delivered to body tissues (Brunner &Suddarth, p.877). Bleeding may only be related to anemia if the cause of anemia is excessive bleeding and/or bone marrow suppression (which is not specified in this situation). 57. A client with congenital heart disease is suffering from thickening of the skin under his fingers due to chronic hemoglobin desaturation. Which of the following specific term should Ime use to accurately describe MOST the client’s condition in the chart? A. Peripheral cyanosis – Peripheral cyanosis, a bluish tinge, most often of the nails and skin of the nose, lips, earlobes, and extremities, suggests decreased flow rate of blood to a particular area (Brunner &Suddarth, p.662) B. Pallor of the finger tips – pallor is a decrease in the color of the skin, which is caused by lack of oxyhemoglobin (Brunner &Suddarth, p.662) C. Peripheral neuropathy – a disorder characterized by sensory loss, pain, muscle weakness, and wasting of muscles in the hands or legs and feet (Brunner &Suddarth, p.1548) D. Clubbing of the fingers – clubbing is manifested by a straightening of the normal angle (180 degrees or greater) and softening of the nail base(Brunner &Suddarth, p.1647). In clubbing, the distal phalanx of each finger is rounded and bulbous; among the many causes is chronic hypoxia (which is the cause for patients with anemia) (Brunner &Suddarth, p.474). 58. When the Nurse is assessing a client with Congestive Heart failure with pitting edema, the Nurse’s documentation will include which of the following: A. Degree of pitting edema B. Time of indention recovery C. Depth of edema D. All of the options 59. Mr. Gabby is with left sided heart failure. Janine’s documentation of her assessment findings will include the following, EXCEPT______________. A. Dependent edema – is the edema of the lower extremities, which worsens when the patient stands or dangles the legs, and decreases when the patient elevates the legs.This is a clinical manifestation of right-sided heart failure. In this condition, the right ventricle fails, leading to the congestion of the viscera. This occurs because the right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. This leads to increased venous pressure, further leading to JVD (Brunner &Suddarth, p.795). B. Pulmonary crackles C. Difficulty of breathing D. Cough 60. A client is on a diuretic therapy. Expected entry in patient’s chart should include the following information, EXCEPT: A. Serum electrolytes monitored – nursing care for patients on diuretic therapy must include checking laboratory results for electrolyte depletion, especially potassium, magnesium and sodium; and for electrolyte elevation, especially potassium with potassium-sparing agents and calcium with thiazides (Brunner &Suddarth, p.807). B. Intake and output recorded – output must be measured carefully to establish a baseline against which to measure the effectiveness of the diuretic therapy; intake and output records must be rigorously maintained (Brunner &Suddarth, p.801). C. Lasix administered at 8 o’clock in the evening – patients receiving diuretic therapy may excrete a large volume of urine within minutes after a potent diuretic is administered (Brunner &Suddarth, p.806). Hence, diuretics must be administered early in the day to avoid nocturia(Brunner &Suddarth, p.807). D. Weight is taken before drug is given – patients with heart failure are weighed daily, at the same time of day, with the same type of clothing, and on the same scale to determine effectiveness of the diuretic therapy. Significant changes in weight must be watched out for (Brunner &Suddarth, p.801). Situation 1 – The TQM nurse reported to their director that there are a lot of medication errors committed by nurses and doctors in the hospital for the past 3 months. They made a decision to conduct a review of all the cases with these errors. A clinical enhancement on drug administration was strongly recommended by going back to the basics. The following questions apply: 61. Which of the following techniques in injection should the nurse use to minimize pain when administering imferon (Iron drugs). 1. Z_track technique 2. “Darting” needle quickly 3. Withdraw needle quickly 4. Inject medication quickly A. 2 and 3 B. 1, 2 and 4 C. 1 and 2 D. 1, 2, 3 and 4 62. In order to prevent error in insulin injection which of the following safety measure should you do? A. Leave the drug in the client refrigerator and ask it when needed. B. Double check with your head nurse calculations and consider high “alert” drugs. C. Compute the drug, proceed to the patient, and administer the drug. D. Request the dietary department to keep the drug until needed. 63. When giving injections to obese client, which of the following needle size should you use? A. 4 inch needle B. 2-3 inch needle C. 4 1⁄2 inch needle D. 1-1.5 inch needle Situation 2 – Jayson is a 72 year old who is a smoker and a social drinker. He consulted the OPD because of rectal bleeding. His tentative diagnosis is colorectal cancer. He was advised by the doctor for admission. 64. Which of the following would you likely expect as a specific complaint of the client during your initial health history taking? A. Projectile vomiting B. Bouts of hematemesis C. Change in bowel habits D. Passing out white watery stools 65. Colonoscopy has been ordered. Which of the following is not advisable for the client to do? A. Has to drink the electrolyte laxatives day before the procedure TOP RANK REVIEW ACADEMY, INC. Page 4 | 6