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A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
- A. Where is the pain located?
- B. What causes the pain?
- C. Does it come and go?
- D. What does the pain feel like?
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? This question corresponds to the "P" in PQRST, which stands for Provocation/Palliation. By asking where the pain is located, the nurse is gathering information about what triggers or relieves the pain, aiding in the assessment of the chest pain. The other choices are incorrect because:
B: What causes the pain? - This question corresponds to the "Q" in PQRST, which stands for Quality. It focuses on understanding the characteristics of the pain, not the cause.
C: Does it come and go? - This question corresponds to the "R" in PQRST, which stands for Radiation. It pertains to whether the pain spreads to other areas, not if it comes and goes.
D: What does the pain feel like? - This question corresponds to the "S" in PQRST, which stands for Severity. It relates to the intensity of the pain, not its location.
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A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
- A. Above-normal urine and serum osmolality levels
- B. Below-normal urine and serum osmolality levels
- C. Above-normal urine osmolality level, below-normal serum osmolality level
- D. Below- normal urine osmolality level, above-normal serum osmolality level
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus.
Explanation for other choices:
A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus.
B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus.
C: Above-normal urine osmolality level, below-normal
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
- A. strict isolation techniques and policies
- B. a semi-private room
- C. liberal, unrestricted visiting
- D. equipment shared between Mr. Boy and the other burn patients in the unit
Correct Answer: B
Rationale: The correct answer is B: a semi-private room. For a burn patient like Mr. Boy, a semi-private room is preferred to provide a more controlled environment for infection prevention, wound care, and privacy. Strict isolation (A) is not necessary as his burns are not infectious. Liberal visiting (C) can increase the risk of infection and compromise his recovery. Sharing equipment (D) can lead to cross-contamination and is not recommended for burn patients. In summary, a semi-private room balances infection control and patient comfort for burn patients.
A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?
- A. Apply a cold compress to the injured eye
- B. Apply a light bandage to the eye
- C. perform an assessment on the client
- D. flush the eye continuously with sterile solution
Correct Answer: D
Rationale: The correct answer is D: flush the eye continuously with sterile solution. This is the first action because it helps to remove the chemical from the eye, preventing further damage. Flushing with sterile solution dilutes and washes away the chemical, reducing the risk of ongoing injury. Applying a cold compress (A) may help with pain but does not address the chemical exposure. Applying a bandage (B) can trap the chemical and worsen the injury. Performing an assessment (C) should come after immediate treatment to ensure proper care but should not delay flushing the eye.
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
- A. antidiuretic hormone (ADH).
- B. follicle-stimulating hormone (FSH).
- C. thyroid-stimulating hormone (TSH).
- D. luteinizing hormone (LH).
Correct Answer: A
Rationale: The correct answer is A: antidiuretic hormone (ADH). In diabetes insipidus, there is a deficiency of ADH, which regulates water balance by reducing urine output. Without ADH, excessive urination and thirst occur. FSH, TSH, and LH are not related to water balance regulation. FSH and LH are involved in reproductive functions, while TSH regulates thyroid hormone production. Therefore, the nurse should focus on educating the client about the importance of ADH in managing diabetes insipidus.
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
- A. orthopnea
- B. fever
- C. weight loss
- D. calf pain A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET O
Correct Answer: A
Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat.
Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe.
Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection.
Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF.
Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF.
Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.