Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: Providing new information slowly and in small amounts to a confused individual, like Mr. Reyes, is important because confusion or delirium can be a defense mechanism against further stress. By giving information gradually, it allows the individual to better absorb and process the information without becoming overwhelmed, which can further exacerbate their confusion. This approach also helps reduce the risk of causing additional stress or agitation in the individual, thus promoting a more conducive environment for cognitive processing and understanding.
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The LEAST important advice for a 2-month-old baby with excessive crying is
- A. master the situation in relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing formula may not address refusal due to developmental factors.
The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?
- A. Examine the entire system and tubing for air leaks.
- B. Lower the level of suction.
- C. Nothing; vigorous bubbling is expected
- D. Ask the patient to cough forcefully.
Correct Answer: A
Rationale: The nurse should examine the entire system and tubing for air leaks when observing vigorous bubbling in the water-seal chamber of a chest-drainage system. Vigorous bubbling indicates that there is air escaping from the system, which can lead to suboptimal drainage and potential complications. By identifying and correcting any air leaks, the nurse can ensure the chest-drainage system functions effectively, allowing for proper drainage and the prevention of complications such as pneumothorax. Lowering the level of suction or asking the patient to cough forcefully would not address the underlying issue of air leaks and may not resolve the problem effectively.
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: In the case of Mr. Dela Isla, who suffered a CVA, one of the most important discharge teachings would be drug compliance. Following a stroke, patients are often prescribed medications to help manage their condition and reduce the risk of further complications. It is crucial for Mr. Dela Isla to understand the importance of taking his medications as prescribed by his healthcare provider. Non-compliance with medication regimens can have serious consequences and may increase the likelihood of recurrent strokes or other health issues. Therefore, ensuring that Mr. Dela Isla understands the purpose of his medications, how to take them correctly, and the potential side effects is essential for his recovery and ongoing health management. While emergency numbers, relaxation techniques, and dietary prescriptions are important aspects of care, ensuring drug compliance is critical for the immediate and long-term well-being of a patient who has experienced a stroke.
A male client recently underwent a surgical procedure for a malignant tumor. As a result of the surgery, his urine is diverted to a stomal pouch. What should the nurse suggest so that he remains odor free.
- A. Eating spicy foods
- B. Drinking cranberry juice
- C. Eating eggs, asparagus, or cheese
- D. Drinking tea, coffee and colas
Correct Answer: B
Rationale: Drinking cranberry juice can help decrease the odor of urine due to its acidic nature. The acid in cranberry juice can help neutralize odors in the urine, making it less noticeable. In contrast, consuming spicy foods (choice A) can actually increase the odor of urine. Similarly, choices C and D (eating eggs, asparagus, or cheese; drinking tea, coffee, and colas) can contribute to stronger-smelling urine due to the compounds they contain. Therefore, recommending cranberry juice to the male client with a stomal pouch is the most appropriate choice to help him remain odor-free.
the best prophylactic treatment to prevent further rheumatic fever attack:
- A. prednisone
- B. aspirin
- C. penicillin
- D. paracetamol
Correct Answer: C
Rationale: The best prophylactic treatment to prevent further rheumatic fever attacks is penicillin. Penicillin is recommended for long-term secondary prophylaxis to prevent the recurrence of acute rheumatic fever and reduce the risk of rheumatic heart disease. It helps to eradicate streptococcal infections, which are the underlying cause of rheumatic fever. Prednisone, aspirin, and paracetamol are not used for primary or secondary prevention of rheumatic fever.