Nokea
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which of the following would be an appropriate response by the nurse?
- A. "How does your family react to your pain?"
- B. "That must be terrible. You probably pinched a nerve."
- C. "I've had back pain myself, and I know it can be excruciating."
- D. "How would you say the pain affects your ability to carry on your daily activities?"
Correct Answer: D
Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment.
Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.
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Which of the following statements is a characteristic of the clinical practice guidelines for infants and children for a periodic health examination?
- A. They are used to diagnose an illness.
- B. They are helpful in identifying developmental delays in children.
- C. They recommend that every individual receive an annual physical examination.
- D. They list a frequency schedule for periodic health visits for a specific age group.
Correct Answer: D
Rationale: The correct answer is D because clinical practice guidelines for periodic health examinations provide a frequency schedule for health visits based on age. This is crucial for ensuring timely preventive care and monitoring of growth and development. Choice A is incorrect as guidelines focus on preventive care, not diagnosing illnesses. Choice B is incorrect because while guidelines may mention developmental milestones, their primary focus is on health maintenance. Choice C is incorrect as guidelines recommend health visits based on individual needs, not a one-size-fits-all annual physical examination.
The nurse is assessing a teenage girl newly admitted to the pediatric unit. What efficient framework provides additional modesty?
- A. Body systems
- B. Functional
- C. Focused
- D. Head to toe
Correct Answer: D
Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy.
A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach.
B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health.
C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.
During a follow-up visit, the nurse discovers that the patient has not been taking his insulin regularly. The nurse asks, "Why haven't you taken your insulin?' Which of the following is an appropriate evaluation of this question?
- A. It may put the patient on the defensive.
- B. It is an innocent attempt to get information.
- C. It would have been better to discuss this with his wife.
- D. It is the best way to discover the reasons for his behaviour.
Correct Answer: A
Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship.
Explanation of other choices:
B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue.
C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy.
D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.
Which factor is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Rationale:
1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members.
2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem.
3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image.
4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image.
Summary:
Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.
Which disease is least likely to be associated with increased potential for bleeding?
- A. metastatic liver cancer
- B. gram-negative septicemia
- C. pernicious anemia
- D. iron-deficiency anemia
Correct Answer: C
Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.