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A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
- A. How do you usually feel? Is this normal behaviour for you?
- B. I am going to say four words. In a few minutes, I will ask you to recall them.
- C. Please describe the meaning of the phrase, "looking through rose-coloured glasses.'
- D. Please pick up the pencil in your left hand, move it to your right hand, and place it on the table.
Correct Answer: D
Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness.
Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.
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A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
- A. Severe headache
- B. Dehydration
- C. Respiratory depression
- D. Sudden loss of vision
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.
What is the correct interpretation of a drumlike sound heard during percussion of the abdomen?
- A. Constipation
- B. Air-filled areas
- C. The presence of a tumor
- D. The presence of dense organs
Correct Answer: B
Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination.
Incorrect Answers:
A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention.
C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion.
D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.
A nurse is assessing a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Administering pain medication as needed.
- B. Encouraging deep breathing and coughing exercises.
- C. Monitoring for signs of infection.
- D. Providing wound care and dressing changes.
Correct Answer: B
Rationale: The correct answer is B because deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia after abdominal surgery. By promoting lung expansion and clearing secretions, these exercises enhance oxygenation and prevent respiratory issues. Administering pain medication (A) is important but not the priority. Monitoring for infection (C) and providing wound care (D) are also crucial but come after ensuring respiratory function.
A nurse is teaching a patient with diabetes about managing their condition. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood glucose regularly.
- B. I can stop taking my insulin when my blood glucose is normal.
- C. I should only use my insulin when I feel symptoms of high blood sugar.
- D. I will eat sugary foods if I feel tired or weak.
Correct Answer: A
Rationale: The correct answer is A: "I will monitor my blood glucose regularly." This statement shows proper understanding as monitoring blood glucose levels is essential for managing diabetes effectively. Regular monitoring helps the patient track their blood sugar levels and make informed decisions about medication, diet, and lifestyle.
Incorrect choices:
B: Stopping insulin when blood glucose is normal can lead to dangerous complications.
C: Using insulin only when symptoms of high blood sugar are present is not a safe or effective approach.
D: Eating sugary foods when feeling tired or weak can cause blood sugar spikes and worsen diabetes control.
In summary, choice A is correct because it reflects the importance of consistent blood glucose monitoring in diabetes management, while the other choices suggest potentially harmful misconceptions.
During her prenatal checkup, a patient begins to cry as the nurse asks her about previous pregnancies. The patient says that she is remembering her last pregnancy, which ended in miscarriage. The nurse's best response to her crying would be:
- A. "I'm so sorry for making you cry!"
- B. "I can see that you are sad remembering this. It is all right to cry."
- C. "Why don't I step out for a few minutes until you're feeling better?"
- D. "I can see that you feel sad about this; why don't we talk about something else?"
Correct Answer: B
Rationale: The correct answer is B because it shows empathy and validation towards the patient's emotions. By acknowledging the patient's sadness and giving her permission to cry, the nurse creates a safe and supportive environment. This response helps the patient feel understood and accepted, facilitating emotional expression and potentially leading to a deeper therapeutic relationship.
Choice A is incorrect because it focuses on the nurse's discomfort rather than the patient's feelings. Choice C is incorrect as it may come across as dismissive of the patient's emotions. Choice D is incorrect as it suggests avoiding the topic rather than addressing the patient's feelings directly.