Nokea
A 24 year-old man has been admitted to the hospital due to work-related back injury. The patient's wife would like to see the patient's chart. The nurse should:
- A. Provide the chart to the patient's wife following verbal approval by the patient.
- B. Provide the chart to the patient's wife after consulting with the patient's physician.
- C. Get written approval from the patient prior to providing the wife with chart information and call the MD about the patient's request.
- D. Tell the patient's wife, a copy of the patient's medical record is on-file with medical records.
Correct Answer: C
Rationale: Some facilities require the physician to be notified about a patient's request and written permission from the husband is required for the wife to view the chart.
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A nurse is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?
- A. Horizontal
- B. Sagittal
- C. Frontal
- D. Vertical
Correct Answer: B
Rationale: Sagittal motion occurs in the midline plane of the body.
Which of the following describes the stages of domestic violence in an intimate relationship?
- A. Happiness, crisis, angry outburst, intervention
- B. Honeymoon period, escalation of stress, outburst, reconciliation
- C. Acting out and making up
- D. Peace and calm, angry outburst, peace and calm, denial
Correct Answer: B
Rationale: The cycle of abuse includes a honeymoon phase, stress escalation, an outburst (often violent), and reconciliation, increasing the risk of harm if unaddressed.
A nurse is assessing a patient's breath sounds. The patient has had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?
- A. Decreased breath sound volume
- B. Elevated tidal volume
- C. Elevated respiratory capacity
- D. Wheezing
Correct Answer: A
Rationale: Breath sounds would be softer due to the removal of the right lung, reducing the area available for air exchange.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
- A. temperature of 102°F and a productive cough
- B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
- C. trachea deviating to the right
- D. barrel-chested appearance
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.
James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
- A. denial.
- B. suppression.
- C. displacement.
- D. fantasy.
Correct Answer: C
Rationale: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object.