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A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following assessments?
- A. Oxygen saturation levels.
- B. Pain levels.
- C. Bowel sounds.
- D. Level of consciousness.
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.
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A First Nations woman has come to the clinic for diabetes follow-up teaching. During the interview, the nurse notices that the patient never makes eye contact and speaks mostly looking down at the floor. Which of the following statements about this situation is true?
- A. She is nervous and embarrassed.
- B. She has something to hide and is ashamed.
- C. She is showing inconsistent verbal and nonverbal behaviours.
- D. She is showing that she is listening carefully to what the nurse is saying.
Correct Answer: D
Rationale: The correct answer is D because the patient's behavior of not making eye contact and looking down can be a sign of active listening and respect in some cultures, including many First Nations cultures. This behavior may indicate that the patient is focusing on what the nurse is saying and showing attentiveness. Making eye contact may be considered disrespectful or challenging in some cultures, so the lack of eye contact does not necessarily mean the patient has something to hide, is ashamed, or is nervous. Choice A assumes the patient is nervous or embarrassed without evidence. Choice B is an assumption without any basis, and choice C does not consider cultural differences in communication styles.
A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 4.5 kg (10 lb) in the past month. Which of the following is the nurse's best response in this situation?
- A. Do you own any lethal weapon?
- B. How do other people treat you?
- C. Are you feeling so hopeless that you feel like hurting yourself now?
- D. People often feel hopeless, but the feeling resolves within a few weeks.
Correct Answer: C
Rationale: The correct answer is C: "Are you feeling so hopeless that you feel like hurting yourself now?" This response directly addresses the patient's suicidal ideation and assesses the immediate risk of harm. It shows the nurse's concern for the patient's safety and allows for further evaluation and intervention if necessary.
Option A is incorrect because asking about owning a lethal weapon does not directly address the patient's current mental state and immediate risk of harm. Option B is incorrect as it focuses on external factors rather than the patient's internal feelings of hopelessness and suicidal thoughts. Option D is incorrect as it minimizes the seriousness of the patient's symptoms and may lead to overlooking the urgency of the situation.
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should prioritize which of the following interventions?
- A. Encouraging regular foot inspections.
- B. Providing additional protein to the diet.
- C. Encouraging weight loss to reduce joint stress.
- D. Administering pain medication for relief.
Correct Answer: A
Rationale: The correct answer is A: Encouraging regular foot inspections. This is the priority intervention because diabetic neuropathy can lead to decreased sensation in the feet, increasing the risk of injury or infection. Regular foot inspections can help detect any issues early and prevent complications.
Incorrect choices:
B: Providing additional protein to the diet - While nutrition is important for overall health, providing additional protein does not directly address the specific issue of diabetic neuropathy.
C: Encouraging weight loss to reduce joint stress - Weight loss may be beneficial for overall health, but it is not the priority intervention for diabetic neuropathy.
D: Administering pain medication for relief - Pain management is important, but addressing the root cause through regular foot inspections is more essential in preventing further complications.
When providing culturally competent care, nurses must incorporate cultural assessment into their health assessment. Which statement is most appropriate to use when initiating a cultural beliefs assessment with a First Nations elder?
- A. Are you of the Christian faith, or another faith?
- B. Do you want to see a medicine man?
- C. How often do you seek help from medical providers?
- D. What cultural or spiritual beliefs are important to you?
Correct Answer: D
Rationale: The correct answer is D: "What cultural or spiritual beliefs are important to you?" This question allows the nurse to understand the elder's values and beliefs, guiding care. A: Assumes a specific faith. B: Stereotypes the elder. C: Focuses on frequency of medical visits, not beliefs.
Which statement is correct regarding the development of one's culture?
- A. Culture is genetically determined on the basis of racial background.
- B. Culture is rooted in several distinctive and specific social elements.
- C. Culture is a nonspecific phenomenon and is adaptive, but unnecessary.
- D. Culture is biologically determined on the basis of physical characteristics.
Correct Answer: B
Rationale: The correct answer is B because culture is indeed rooted in specific social elements such as language, customs, traditions, beliefs, and values. These elements are passed down through generations within a particular society or group. Choice A is incorrect because culture is not genetically determined, but rather learned and acquired through socialization. Choice C is incorrect as culture plays a crucial role in shaping identities, behaviors, and interactions within a society. Choice D is incorrect as culture is not biologically determined, but rather socially constructed.