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Which technique should be used to assess a murmur in a patient's heart?
- A. The bell of the stethoscope
- B. The diaphragm of the stethoscope
- C. Palpation with the palm of the hand
- D. Ask another nurse to double-check the finding.
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location.
A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs.
C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs.
D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.
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A nurse is caring for a patient with a history of hypertension. The nurse should prioritize which of the following interventions?
- A. Administering antihypertensive medication as prescribed.
- B. Encouraging weight loss.
- C. Monitoring blood pressure regularly.
- D. Promoting a low-sodium diet.
Correct Answer: A
Rationale: The correct answer is A: Administering antihypertensive medication as prescribed. This is the priority intervention because it directly addresses the patient's hypertension, which is a critical condition that needs immediate management to prevent complications. Encouraging weight loss (B), monitoring blood pressure (C), and promoting a low-sodium diet (D) are all important aspects of managing hypertension. However, administering antihypertensive medication takes precedence as it directly targets lowering blood pressure and reducing the risk of cardiovascular events. Weight loss, monitoring, and dietary changes are important for long-term management but may not provide immediate control of hypertension compared to medication.
Which of the following statements illustrates the biomedical model of Western traditional views?
- A. Health is viewed as the absence of disease.
- B. Optimal health is viewed as high-level wellness.
- C. Health and disease are considered parts of a cyclical process.
- D. The treatment of disease is nursing's primary focus.
Correct Answer: A
Rationale: The correct answer is A because the biomedical model focuses on defining health as the absence of disease. This model emphasizes biological factors in understanding and treating illnesses. It is reductionist in nature, viewing health issues as purely physical and separate from social or psychological aspects. Choices B, C, and D do not align with the biomedical model. B emphasizes overall well-being, not just the absence of disease. C suggests a more holistic approach, while D implies a focus on nursing rather than the medical model's emphasis on disease treatment.
A 32-year-old female patient complains that she has noticed several small, slightly raised, bright-red dots on her chest. On examination, the nurse thinks that the spots are probably:
- A. Anasarca.
- B. Scleroderma.
- C. Senile angiomas.
- D. Latent myeloma.
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign growths of small blood vessels that appear as bright-red dots on the skin, commonly seen in older individuals. In this case, the patient is 32 years old, which is relatively young for an appearance of senile angiomas, but still within the possible age range. Anasarca (A) is generalized edema, not related to the described skin condition. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not associated with bright-red dots. Latent myeloma (D) is a type of bone marrow cancer and not related to the skin findings described.
Expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. This is referred to as:
- A. intuition.
- B. the nursing process.
- C. clinical knowledge.
- D. diagnostic reasoning.
Correct Answer: A
Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over her other clothes. Her hair is dyed pink with black streaks. She has several piercings in her nares and ears and is wearing an earring on her eyebrow and heavy black makeup. The nurse concludes that:
- A. She probably does not have any problems at all.
- B. She is just trying to shock people, and her appearance should be ignored.
- C. She has manic syndrome because of her abnormal way of dressing and grooming.
- D. More information should be gathered to decide whether her way of dressing is appropriate.
Correct Answer: D
Rationale: The correct answer is D because more information should be gathered to assess the situation appropriately. The woman's appearance may suggest alternative lifestyles or personal expression rather than mental health issues. It is essential to avoid assumptions based solely on appearance and gather a comprehensive history to understand her choices. Options A and B are dismissive and judgmental, failing to consider the complexity of human behavior. Option C is incorrect as the presented information does not provide enough evidence to diagnose manic syndrome. In summary, option D is the most logical and ethical approach to understanding the woman's situation without making unfounded assumptions.