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A 16-year-old boy has just been admitted for overnight observation after being in an automobile accident. What is the nurse's best approach to communicating with him?
- A. Use periods of silence to communicate respect for him.
- B. Be totally honest with him, even if the information is unpleasant.
- C. Tell him that everything that is discussed will be kept totally confidential.
- D. Use slang language when possible to help him open up.
Correct Answer: B
Rationale: The correct answer is B: Be totally honest with him, even if the information is unpleasant. This is the best approach because honesty builds trust and credibility, crucial in a healthcare setting. It allows the teenager to make informed decisions about his care and fosters a therapeutic relationship.
Explanation for why the other choices are incorrect:
A: Using periods of silence may be misinterpreted as indifference or lack of engagement.
C: Promising total confidentiality may not be feasible in healthcare settings and could lead to potential harm if critical information needs to be shared with others for the patient's safety.
D: Using slang language may come across as unprofessional and may hinder effective communication and understanding between the nurse and the patient.
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An example of objective information obtained during the physical assessment includes the patient's:
- A. history of allergies.
- B. use of medications at home.
- C. last menstrual period.
- D. 2 cm x 5 cm scar present on the right forearm.
Correct Answer: D
Rationale: The correct answer is D because the presence of a physical characteristic like a scar is an objective finding that can be directly observed and measured during a physical assessment. This information is not subject to interpretation or bias. In contrast, choices A, B, and C involve subjective information that relies on the patient's report or memory, making them less reliable and objective. History of allergies (A) and use of medications (B) are subjective and based on the patient's self-report, while last menstrual period (C) is also subjective and may not always be accurate. Therefore, choice D is the only objective piece of information among the options provided.
A nurse is caring for a patient with hypertension. The nurse should educate the patient to monitor for which of the following complications?
- A. Severe headaches and blurred vision.
- B. Weight loss and fatigue.
- C. Increased appetite and tremors.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A: Severe headaches and blurred vision. These symptoms can indicate a hypertensive crisis, a severe complication of hypertension. Headaches and blurred vision are signs of potentially dangerous high blood pressure levels. Weight loss and fatigue (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typical complications of hypertension and do not directly relate to the cardiovascular effects of high blood pressure. Monitoring for severe headaches and blurred vision is crucial for early detection and management of hypertensive crises.
A nurse is teaching a patient with a new diagnosis of diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood glucose levels regularly.
- B. I should follow a healthy diet to manage my condition.
- C. I can stop taking my insulin when my blood sugar is normal.
- D. I will exercise regularly to improve my health.
Correct Answer: C
Rationale: The correct answer is C: "I can stop taking my insulin when my blood sugar is normal." This statement indicates a misunderstanding of diabetes management. Here's the rationale:
1. Insulin is a crucial medication for managing diabetes, and stopping it abruptly can lead to serious complications.
2. Blood sugar levels can fluctuate, so stopping insulin when levels are normal is not safe or effective.
3. Proper education should emphasize the importance of consistent insulin use as prescribed by healthcare providers.
4. Choices A, B, and D demonstrate good understanding of diabetes management by focusing on monitoring blood glucose levels, following a healthy diet, and exercising regularly.
A nurse is caring for a patient with a history of myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administering pain medication.
- B. Monitoring vital signs and oxygen saturation.
- C. Encouraging deep breathing exercises.
- D. Providing nutritional education.
Correct Answer: B
Rationale: The correct answer is B: Monitoring vital signs and oxygen saturation. This is the priority intervention because it allows the nurse to assess the patient's current cardiac status and detect any potential complications early. Monitoring vital signs provides crucial information on the patient's cardiovascular stability, while oxygen saturation levels indicate adequate tissue perfusion. Administering pain medication (A) can be important but not the priority. Deep breathing exercises (C) and providing nutritional education (D) are important but not as immediate as monitoring vital signs and oxygen saturation in a patient with a history of myocardial infarction.
The nurse is obtaining a history from a 30-year-old male patient and is concerned about the adequacy of his health promotion activities. Which one of the following questions would be appropriate in this situation?
- A. "Do you perform testicular self-examinations?"
- B. "Have you ever noticed any pain in your testicles?"
- C. "Have you had any problems with passing urine?"
- D. "Do you have any history of sexually transmitted infection?"
Correct Answer: A
Rationale: The correct answer is A: "Do you perform testicular self-examinations?" This question is appropriate as it addresses health promotion activities specific to the patient's age and gender, promoting early detection of testicular cancer.
Explanation:
1. Testicular self-examination is a key health promotion activity for men in their 20s and 30s.
2. It encourages self-awareness and early detection of abnormalities in the testicles.
3. Testicular cancer is most common in younger men, making this question relevant.
4. Options B, C, and D are not directly related to health promotion activities for a 30-year-old male.