Nokea
A 32-year-old patient shares with the nurse that she has been unwell for 2 weeks. She has had a variety of symptoms and has been treating them with herbs that her mother has provideThe nurse should:
- A. tell the patient that it is the herbs that are making her feel unwell.
- B. ask the patient more about the effects of the herbs.
- C. take a sample of the herbs to send to the laboratory for analysis.
- D. ask the patient's mother to explain the use of the herbs.
Correct Answer: B
Rationale: The correct answer is B because the nurse needs more information to assess the situation effectively. By asking the patient more about the effects of the herbs, the nurse can gather crucial details about the patient's condition and the potential impact of the herbs on her health. This will help the nurse make an informed decision on the appropriate course of action.
Choice A is incorrect because jumping to conclusions without gathering more information can be detrimental to the patient's care. Choice C is incorrect as sending the herbs for analysis may not provide immediate insights into the patient's condition. Choice D is incorrect as the focus should be on directly obtaining information from the patient rather than involving a third party.
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What immediate intervention should a nurse provide for a hypoglycemic client?
- A. one commercially prepared glucose tablet
- B. two hard candies
- C. 4-6 ounces of fruit juice with sugar
- D. 2-3 teaspoons of honey
Correct Answer: C
Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.
When listening to a patient's breath sounds, the nurse is unsure about a sound that is hearThe nurse should:
- A. notify the patient's physician immediately.
- B. document the sound exactly as it was heard.
- C. validate the data by asking a colleague to listen to the breath sounds.
- D. assess again in 20 minutes to note whether the sound is still present.
Correct Answer: C
Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
- A. "It is a sharp, burning pain in my stomach."
- B. "I also have the sweats and nausea when I feel this pain."
- C. "I think this pain is telling me that something is wrong with me."
- D. "This pain happens every time I sit down to use the computer."
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
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.
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.