Nokea
A nurse is assisting in the admission of a young adult female Korean exchange student with acute abdominal pain. When asked about her sexual activity, she looks away. What should the nurse do?
- A. Omit this question from the assessment form
- B. Ask her if she would like an interpreter present to assist with communication
- C. Reword the question to ensure the client's understanding
- D. Watch the client's response when asked a different question
Correct Answer: D
Rationale: Observing the client's response to a different question can help gauge her comfort level and understanding, which is essential in culturally sensitive care. By watching her response to a different question, the nurse can assess if the discomfort is related to the specific question or a broader issue. Omitting the question may result in missing crucial information. Asking about an interpreter assumes that the language barrier is the only issue, which may not be the case. Rewording the question may not address the underlying discomfort and could still lead to misinterpretation.
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Which condition is characterized by a progressive loss of muscle strength due to an autoimmune attack on acetylcholine receptors?
- A. Myasthenia gravis
- B. Multiple sclerosis
- C. Amyotrophic lateral sclerosis
- D. Guillain-Barr© syndrome
Correct Answer: A
Rationale: The correct answer is A: Myasthenia gravis. Myasthenia gravis is characterized by muscle weakness caused by autoimmune attack on acetylcholine receptors at the neuromuscular junction. This results in impaired communication between nerves and muscles. Choice B, Multiple sclerosis, is a condition where the immune system attacks the protective myelin sheath covering the nerves in the central nervous system, leading to communication issues between the brain and the rest of the body. Choice C, Amyotrophic lateral sclerosis, is a progressive neurodegenerative disease affecting motor neurons in the brain and spinal cord, not involving acetylcholine receptors. Choice D, Guillain-Barr© syndrome, is an acute condition where the immune system attacks the peripheral nerves, causing muscle weakness and paralysis, but it does not target acetylcholine receptors.
Which intervention is most appropriate when caring for a patient experiencing a tonic-clonic seizure?
- A. Restrain the patient to prevent injury
- B. Place a tongue depressor in the patient's mouth
- C. Turn the patient to the side to maintain an open airway
- D. Attempt to stop the seizure by holding the patient's arms
Correct Answer: C
Rationale: During a tonic-clonic seizure, the priority is to ensure patient safety by maintaining an open airway to prevent aspiration. Turning the patient to the side helps achieve this goal by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration. Restraint can lead to injury, placing a tongue depressor can cause harm or obstruct the airway further, and attempting to stop the seizure by holding the patient's arms is ineffective and can also result in injury. Therefore, the most appropriate intervention is to turn the patient to the side.
The home health PN suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the PN to take?
- A. Document the lacerations in the client's record
- B. Report findings to the supervisor for referral to adult protective services
- C. Ask the daughter who has been taking care of the client on a daily basis
- D. Apply dry dressings after cleansing the wounds
Correct Answer: B
Rationale: The most important action for the PN to take in this situation is to report the findings to the supervisor for referral to adult protective services. Suspected elder abuse must be reported promptly to ensure the safety and protection of the client. Documenting the lacerations in the client's record is important but not as critical as reporting the suspected abuse. Asking the daughter who is the potential abuser may not yield accurate information and could compromise the safety of the client. Applying dressings to the wounds is a lower priority compared to addressing the suspected elder abuse.
The PN is assisting the recreational director of a long-term care facility to plan outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?
- A. An open-air concert
- B. A tea party in the courtyard
- C. A team ring-toss competition
- D. A picnic in the park
Correct Answer: B
Rationale: A tea party in the courtyard is the most suitable activity as it allows for social interaction in a comfortable and accessible environment. Wheelchair-bound residents can easily participate, fostering both physical and social engagement. An open-air concert may pose challenges regarding accessibility and comfort for wheelchair-bound individuals. A team ring-toss competition involves physical activity that may not be inclusive for all residents, especially those in wheelchairs. A picnic in the park may also present challenges related to accessibility and comfort for wheelchair-bound individuals.
Which of the following is a common side effect of opioid analgesics that the nurse should monitor for in patients?
- A. Diarrhea
- B. Hypertension
- C. Constipation
- D. Bradycardia
Correct Answer: C
Rationale: Constipation is a common side effect of opioid analgesics due to the slowing of gastrointestinal motility. Opioids bind to receptors in the gastrointestinal tract, leading to decreased peristalsis and increased water absorption, resulting in constipation. Monitoring for constipation is crucial to prevent discomfort or complications like bowel obstruction. Diarrhea (Choice A) is not a common side effect of opioid analgesics. Hypertension (Choice B) and Bradycardia (Choice D) are not typically associated with opioid use.