Nokea
A 20-year-old construction worker has suffered heat stroke and has been brought into the emergency department. He has delirium as a result of fluid and electrolyte imbalance. The nurse will assess his:
- A. Affect and mood.
- B. Memory and affect.
- C. Thought processes and memory.
- D. Level of consciousness and cognitive abilities.
Correct Answer: D
Rationale: The correct answer is D: Level of consciousness and cognitive abilities. In this scenario, the individual is experiencing delirium due to fluid and electrolyte imbalance, which can affect his level of consciousness and cognitive abilities. Assessing these aspects is crucial in determining the severity of the condition and guiding appropriate interventions. Option A (Affect and mood) is incorrect as the primary concern is the individual's cognitive functioning. Option B (Memory and affect) is incorrect as it does not cover the assessment of consciousness. Option C (Thought processes and memory) is incorrect as it does not specifically address the evaluation of the individual's level of consciousness.
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In response to a question about use of alcohol, a patient asks the nurse why the nurse needs that information. What reason would the nurse give the patient?
- A. This is necessary to determine the patient's reliability.
- B. Alcohol can interact with medications and can make some diseases worse.
- C. The nurse is required to teach the patient about the dangers of alcohol use.
- D. It is not really necessary to ask for this information unless there is an obvious drinking problem.
Correct Answer: B
Rationale: The correct answer is B because alcohol can interact with medications and exacerbate certain medical conditions. The nurse needs this information to ensure the patient's safety and well-being. Choice A is incorrect because the question is not about the patient's reliability. Choice C is incorrect as it assumes the nurse is required to educate the patient about alcohol dangers. Choice D is incorrect because even without an obvious drinking problem, alcohol use can still impact the patient's health.
Which of the following best describes the purpose of a functional assessment?
- A. It assesses how the individual is coping with life at home.
- B. It determines how children are meeting developmental milestones.
- C. It can identify any memory problems an individual may be experiencing.
- D. In the case of the older adult, it helps determine how that person is managing day-to-day activities.
Correct Answer: D
Rationale: The correct answer is D because a functional assessment specifically evaluates an older adult's ability to manage day-to-day activities, such as personal care, meal preparation, and mobility. This assessment helps identify any difficulties the individual may have in performing these essential tasks, which can then inform appropriate interventions or support services. Choices A, B, and C are incorrect because they do not align with the primary focus of a functional assessment, which is to evaluate an individual's functional abilities and independence in daily living tasks, particularly in the context of aging or disability.
A patient with chronic kidney disease (CKD) is being assessed. The nurse would expect to find which of the following symptoms?
- A. Weight loss and polyphagia.
- B. Edema and proteinuria.
- C. Hypertension and tachycardia.
- D. Hypothermia and bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Edema and proteinuria. In CKD, the kidneys are unable to filter waste products effectively, leading to fluid retention (edema) and protein leaking into the urine (proteinuria). Edema occurs due to fluid buildup from decreased kidney function. Proteinuria is a result of damaged glomeruli in the kidneys, allowing proteins to leak into the urine. Weight loss and polyphagia (excessive hunger) are not typical symptoms of CKD. Hypertension and tachycardia can occur in CKD due to fluid overload and electrolyte imbalances. Hypothermia and bradycardia are not common symptoms of CKD and would be more indicative of other conditions.
What should a nurse base their response on when a client asks about an increase in opioid dose for chronic pain?
- A. Body has developed tolerance, requiring more drug
- B. The client is preoccupied with the drug
- C. Addiction is the term for physical dependence
- D. Dual diagnosis of substance abuse and chronic pain
Correct Answer: A
Rationale: The correct answer is A because tolerance is a physiological phenomenon where the body adapts to a drug, requiring higher doses for the same effect. This is a common occurrence with opioids in chronic pain management. Choice B is incorrect as it refers to drug-seeking behavior, not tolerance. Choice C is incorrect because addiction and physical dependence are different concepts. Choice D is incorrect as it relates to a specific scenario of substance abuse alongside chronic pain, not the mechanism behind the need for increased opioid doses in chronic pain management.
What should the nurse assess first in a client with severe abdominal pain?
- A. Assess vital signs
- B. Administer oxygen
- C. Perform an ECG
- D. Monitor serum glucose levels
Correct Answer: A
Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.