Repaso Revalida Parte #1

The correct answer is "negligencia" because the situation described indicates that the client's confusion and attempts to remove the IV and urinary catheter were not properly addressed or prevented by the healthcare provider. This failure to provide appropriate care and supervision resulted in harm to the client, as evidenced by the development of an ulcer in the restricted area. Negligence refers to the failure to exercise reasonable care or fulfill a duty, which is applicable in this case.

The most appropriate response is asking "¿Estás pensando suicidarse?" because it directly addresses the client's statement about not having a reason to live and not being able to go on. This response shows concern for the client's well-being and opens up a dialogue about their thoughts of suicide, allowing for further assessment and intervention if necessary.

Based on the given information, the client is admitted in a psychiatric unit in an agitated state, speaking rapidly, and constantly manipulating their clothes. These symptoms suggest a state of anxiety. The other options, such as deficit of self-care, powerlessness, and impairment of verbal communication, do not align with the symptoms described. Therefore, anxiety is the most appropriate nursing diagnosis for this client.

The nurse understands that the most appropriate response is "Su hijo se ve muy activo, necesita más evaluaciones" because it acknowledges the parents' concerns about their child's behavior and suggests further evaluations to determine the cause of the hyperactivity. This response shows that the nurse is taking the parents' concerns seriously and is advocating for a comprehensive assessment of the child's mental health.

The nurse should see the pediatric client with an actively bleeding femur fracture first. This is because active bleeding can lead to severe blood loss and potentially life-threatening complications. The nurse needs to assess the extent of the bleeding, provide immediate first aid measures, and ensure the client's stability before addressing other concerns.

The professional nurse expects the client to make comments about men trying to sexually seduce her based on the observed behavior of being hyperactive, euphoric, singing loudly, dancing, and wearing excessive makeup. These behaviors are consistent with symptoms of mania, which is often associated with grandiosity, increased energy, and heightened sexuality.

The nurse understands that creating signs and labels for the use of the client is the most appropriate method of communication for a client with expressive aphasia. This method allows the client to visually understand information and communicate their needs and preferences effectively. Writing letters in large size may not be helpful if the client has difficulty understanding written language. Speaking loudly and clearly may not be effective if the client has difficulty comprehending spoken language. Speaking into the ear may not be helpful if the client also has difficulty hearing. Therefore, creating signs and labels is the most suitable option.

This answer acknowledges that the disease is progressive but also offers hope by mentioning that there are options available as the disease progresses. It provides a balanced response that addresses the family's concern while also providing some reassurance that there are potential interventions or support systems that can be explored as the disease worsens.

The professional nurse understands that the most appropriate response or action is to sit beside the client's son and attentively listen to him. This shows empathy and support for the son's feelings of loss and allows him to express his emotions. It is important for the nurse to provide a safe space for the son to grieve and process his emotions without judgment or interruption.

The most appropriate action for the nurse to take in this situation is to motivate the client and assist them in their personal hygiene. This is because the client is feeling tired and does not want to bathe, so the nurse should provide encouragement and support to help them overcome their resistance and ensure their personal hygiene needs are met.

The nurse understands that there are both advantages and disadvantages to bariatric surgery. This response shows that the nurse is knowledgeable about the procedure and is aware that it may not be the right choice for everyone. By acknowledging the potential drawbacks, the nurse is providing a balanced perspective and allowing the patient to make an informed decision.

The professional nurse understands that they should first observe the client's skin and respiratory state because a saturation of oxygen at 80% indicates that the client may be experiencing hypoxemia. By observing the skin and respiratory state, the nurse can assess for signs of cyanosis or labored breathing, which could indicate a worsening respiratory condition. This assessment is important before considering other actions such as checking the monitor cable or calling respiratory therapy.

The correct answer is to ask the client if they are experiencing pain. This is the most appropriate initial action because the client may be experiencing pain despite not requesting medication for it. The client's symptoms of diaphoresis and furrowing of the brow suggest that they may be in pain, and it is important for the nurse to assess the client's pain level and provide appropriate pain relief if necessary.

Given the client's age and the recent CBC results, the nurse recognizes that preventing falls is the most important goal. The low platelet count and hemoglobin level indicate a potential risk for bleeding and anemia, which can increase the client's risk of falls and injuries. Therefore, preventing falls is crucial to ensure the client's safety and well-being.

The LPN should be assigned to the client who requires changes of dressings on their leg because this task falls within the scope of practice for LPNs. Instructing a client who will be discharged, caring for a client with a recent mastectomy and low blood pressure, and assisting a client with a new colostomy are tasks that typically require a higher level of nursing expertise and would be better suited for a registered nurse.

The professional nurse should see the client with Alzheimer's walking in the hallways first. This client may be at risk of wandering and getting lost or injured. Ensuring their safety is a priority. The other clients have specific medical conditions that require attention, but they are not in immediate danger like the client with Alzheimer's.

The professional of the emergency nursing should see the client with third-degree burns on the face and neck first because burns of this severity can be life-threatening and require immediate medical attention. Comatose clients, clients with dilated pupils, clients with gunshot wounds, and clients with a history of seizures should also receive prompt medical care, but the severity of the burns takes precedence in this situation.

The correct initial action for the nurse in this situation is to obtain information about the client's medical history and symptoms. This is important in order to assess the severity and potential causes of the chest pain. It allows the nurse to gather important information that can help guide further actions and decisions, such as whether to send the client to the nearest hospital or instruct them to rest and see their doctor in the morning.

The three-year-old child who is drooling and has their tongue sticking out should be seen first by the emergency nurse. This could be a sign of a blocked airway or an allergic reaction, which can be potentially life-threatening. It is important to assess and intervene immediately to ensure the child's airway is clear and to prevent any further complications.

The correct answer is "Cliente confundido debido a hipoxia." The client's irritability and displaced behavior can be attributed to hypoxia, which is a condition characterized by a lack of oxygen supply to the body's tissues. Hypoxia can lead to confusion, agitation, and irritability. In this case, the client's respiratory condition of emphysema may be causing a decrease in oxygen levels, resulting in confusion and irritability.

El uso del mismo estetoscopio en un cliente post operado del corazón y un cliente con infección de staphy/ococcusaureus es un ejemplo de negligencia porque pone en riesgo la salud del cliente post operado al exponerlo a una posible infección. El profesional de enfermería debería seguir protocolos de higiene y utilizar equipo estéril para prevenir la propagación de infecciones. Esta acción muestra falta de cuidado y atención a la seguridad del paciente, lo cual es considerado negligencia en el ámbito de la enfermería.

Before sending the client for a cardiac catheterization procedure, it is most important for the nursing professional to locate and note the presence of peripheral pulses. This is crucial as it helps assess the client's circulatory status and ensures adequate blood flow to the extremities during and after the procedure. It also serves as a baseline for comparison post-procedure to identify any potential complications such as arterial occlusion or thrombosis.

En el cambio de guardia, el profesional de enfermería está violando el derecho de confidencialidad del cliente al informar sobre el abuso que el cliente sufrió en su infancia. La confidencialidad del cliente es un principio ético fundamental en la atención médica, y divulgar información personal y sensible sin el consentimiento del cliente es una violación de ese derecho.

The best assignment for the two-month-old infant with gastroenteritis would be a private room without a bathroom. This is because infants with gastroenteritis may have frequent episodes of diarrhea and vomiting, which can lead to a risk of spreading infection to other patients. By placing the infant in a private room, the risk of transmission to other patients is minimized. Additionally, a private room provides a quieter and more controlled environment for the infant to rest and recover.

The most appropriate activity for the nurse to assign to the client is the cleaning of the dining room. This activity can provide structure and a sense of responsibility to the client, while also keeping them occupied and productive. It can also help to instill a sense of discipline and routine, which can be beneficial in the rehabilitation process. Additionally, assigning a task like cleaning can help the client develop a sense of pride and accomplishment, which can contribute to their overall well-being and recovery.

The correct answer suggests that the client needs more instruction because they are asking about possible side effects of the steroid treatment. This indicates that they may not have been adequately informed about the potential adverse effects and need further clarification from the nurse.

El profesional de enfermería debe ver primero al niño de seis años de edad que se sometió a una amigdalectomía y está tragando frecuentemente. Esta situación puede indicar una complicación postoperatoria, como sangrado o infección, que requiere atención médica inmediata. Los otros casos también pueden requerir atención, pero no parecen tan urgentes como el niño que ha sido sometido a una cirugía reciente y presenta síntomas preocupantes.

The professional nurse understands that the client's comment "últimamente me dan mareos" is the most important because it indicates a potential symptom of heart failure. Dizziness or lightheadedness can be a sign of reduced blood flow to the brain, which may be related to the congestive heart failure and pacemaker. Swelling of the feet, diarrhea, and poor appetite are also important symptoms to consider, but dizziness is more directly related to the client's cardiovascular condition.

The correct answer is "documentar los resultados." In this scenario, the client arrived at the emergency room complaining of chest pain and with a blood pressure of 120/80 mmHg. They were administered NTG S/L (nitroglycerin sublingual) and half an hour later, the chest pain was relieved and the blood pressure dropped to 88/60 mmHg. In this situation, the nurse should document the results, including the relief of chest pain and the change in blood pressure, for accurate record-keeping and to inform the healthcare team about the client's condition.

The responsibility of the nursing professional in regards to surgical consent is to act as a witness to the client's signature. This means that the nurse is present during the client's signing of the consent form and can attest to the fact that the client willingly and knowingly consented to the surgery. The nurse does not have the responsibility to inform the client of the risks and complications, obtain a copy of the consent form, or sedate the client before signing the consent form.

The nurse should question the assignment of the client with cellulitis in the semi-private room with a diabetic client with an ulcer on the right leg. This is because both clients have conditions that require isolation or special precautions to prevent the spread of infection. Placing them in close proximity could increase the risk of cross-infection or complications for both clients.

The client's low calcium and albumin levels suggest that they may be at risk for developing pressure ulcers or skin breakdown due to prolonged bed rest. Changing the client's position every two hours helps to relieve pressure on specific areas of the body and promote circulation, which can help prevent the development of pressure ulcers. This action takes priority over offering protein-rich meals, providing passive exercises, or adding dairy products to the diet, as preventing skin breakdown is a more immediate concern for the client's overall well-being.

The nurse should see the client who has just arrived from the operating room first because they may require immediate post-operative care and monitoring. This client may have specific needs related to anesthesia, pain management, wound care, and vital sign monitoring that require immediate attention. The other clients, while also important, do not have the same level of urgency as the client who has just come from the operating room.

The nurse understands that the vital equipment that should be placed in the room is the tracheostomy tray. This is because the client underwent a thyroidectomy, which involves the removal of the thyroid gland located in the neck. During this procedure, there is a risk of damage to the trachea, and in some cases, a tracheostomy may be necessary. Therefore, having a tracheostomy tray readily available in the room is important in case the client needs emergency airway management.

The most important clinical finding for a nurse to understand when visiting a diabetic client who is self-administering NPH 20 U s/c q/d AM is blurred vision. Blurred vision can be a sign of high blood sugar levels, which is a common complication in diabetes. It indicates that the client's blood sugar may not be well controlled and further assessment and intervention may be required to prevent potential complications.

After a liver biopsy, the nurse should place the client on the right side. This position helps to prevent bleeding by applying pressure to the biopsy site. Placing the client on the left side or in a supine position may not provide adequate pressure to control bleeding. The semi-fowler's position is not specifically indicated for a liver biopsy.

The most appropriate response is to ask, "¿Cuál es ese trabajo importante que las voces que dicen tienes que hacer?" This response shows empathy and curiosity, allowing the nurse to gather more information about the client's delusions and potentially identify any underlying issues or concerns. It also opens up the opportunity for further discussion and exploration of the client's experiences.

The correct answer is "¿Es posible sentir dolor en el pecho días después del procedimiento?" because the nurse is instructing the client about cardiac catheterization, and this question shows that the client may not have understood that it is normal to experience chest pain after the procedure. The nurse may need to provide further instruction on managing post-procedural pain and when to seek medical attention.

The nurse understands that the most appropriate response is "es parte de la enfermedad, con tratamiento mejorarás" because it acknowledges the client's experience of seeing their body as a rock and reassures them that it is a symptom of their illness. The response also offers hope by stating that with treatment, the client's condition will improve.

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The professional nurse should see the client who received morphine thirty minutes ago first because morphine is a potent opioid analgesic that can cause respiratory depression and sedation. It is important to assess the client's level of consciousness, respiratory rate, and oxygen saturation to ensure their safety and well-being.

The professional nurse from the surgery unit is being sent to the pediatric unit. Among the given clients, the 18-month-old with Bryant's contraction should be assigned to the nurse.

The nurse anticipates that the vital equipment for the client with difficulty breathing and deviated trachea due to a car accident will be a chest tube tray. A chest tube is used to remove air or fluid from the pleural cavity, which can help improve respiratory function and relieve symptoms. This is necessary in cases of pneumothorax or hemothorax, which may occur in trauma patients. Therefore, a chest tube tray would be essential in the emergency room setting for this particular client.

The most appropriate action for the nurse is to reinforce the progress made by the client. This approach acknowledges the client's efforts and achievements, which can help motivate them to continue with their routine exercises. It also provides positive reinforcement and support, which may help address any concerns or fears the client may have about the exercises.

The nurse should see the client who underwent a total thyroidectomy two hours ago first. This procedure involves the removal of the entire thyroid gland, which plays a crucial role in regulating metabolism and other bodily functions. Therefore, it is important for the nurse to assess the client's condition and monitor for any immediate post-operative complications, such as bleeding, difficulty breathing, or changes in vital signs. The other procedures mentioned (popliteal-femoral bypass, total abdominal hysterectomy, and total knee replacement) may also require close monitoring, but the immediate risks associated with a total thyroidectomy make it the priority.

The correct answer is "No veo las serpientes, más veo que está aterrorizado)". This response acknowledges the patient's fear and validates their experience without directly challenging or denying their perception of the snakes. It shows empathy and understanding towards the patient's feelings, which can help build trust and rapport in a therapeutic relationship.

The correct answer is "Cliente con fractura de la cadera interacción." This client requires the expertise of a practical nurse (LPN) due to the specific care needs associated with a hip fracture. LPNs are trained to provide basic nursing care and assist with activities of daily living, which would be necessary for this client's recovery and rehabilitation. The other clients listed may have specific medical needs or procedures, but they do not require the specialized care that an LPN can provide in this situation.

The client with a total hysterectomy done 72 hours ago should be visited first because they may require immediate post-operative care and monitoring for any complications that may arise. This client's condition is time-sensitive and requires close attention from the nurse to ensure proper healing and recovery. The other clients' conditions, while important, do not have the same urgency as a recent surgical procedure.

The highest priority nursing diagnosis for a post-operative client who has just arrived in the recovery room after receiving general anesthesia is "high risk for aspiration." This is because after surgery and anesthesia, the client may have reduced protective airway reflexes, making them more susceptible to aspiration of gastric contents into the lungs. Aspiration can lead to serious complications such as pneumonia and respiratory distress, so it is crucial to closely monitor the client for any signs of aspiration and take appropriate measures to prevent it.

Una meta de enfermería consistente con un cliente de fallo congestivo del corazón sería la disminución de la sobrecarga cardíaca. En el fallo congestivo del corazón, el corazón no puede bombear suficiente sangre para satisfacer las necesidades del cuerpo, lo que puede causar una acumulación de líquido y una sobrecarga en el corazón. Por lo tanto, una meta de enfermería sería reducir esta sobrecarga cardíaca, lo que puede lograrse a través de intervenciones como la administración de diuréticos para eliminar el exceso de líquido y reducir la carga de trabajo del corazón.