Nokea
A 75-year-old woman is at the clinic for a preoperative interview. The nurse is aware that the interview with her may take longer than interviews with younger persons. What is the reason for this?
- A. An older adult has a longer story to tell.
- B. An older adult is usually lonely and likes to have someone to talk to.
- C. Older adults lose much of their mental abilities and require more time to complete an interview.
- D. As a person ages, he or she is unable to hear well, so interviewers usually need to frequently repeat what they say.
Correct Answer: A
Rationale: The correct answer is A because as people age, they accumulate more life experiences, medical history, and details to share. This can lead to longer conversations during interviews. Choice B is incorrect as not all older adults are lonely and seek conversation. Choice C is incorrect because aging does not necessarily equate to a loss of mental abilities. Choice D is incorrect as hearing loss is not a universal issue among older adults and does not significantly impact the length of interviews.
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A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?
- A. Increasing sodium intake.
- B. Losing weight and increasing physical activity.
- C. Consuming more processed foods.
- D. Limiting fluid intake.
Correct Answer: B
Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels.
A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure.
C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure.
D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.
Which of the following questions would best assess a person's judgement?
- A. Do you feel that you are being watched, followed, or controlled?
- B. Tell me about what you plan to do once you are discharged from the hospital.
- C. What does the saying, "People in glass houses shouldn't throw stones' mean to you?
- D. What would you do if you found a stamped, addressed envelope on the sidewalk?
Correct Answer: B
Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.
While auscultating for heart sounds, the nurse hears an unfamiliar sounWhat should the nurse do next?
- A. Document the findings on the patient's record.
- B. Wait 10 minutes, and auscultate the heart again.
- C. Ask another nurse to double-check the finding.
- D. Ask the patient to take deep breaths and check for changes in their physical condition.
Correct Answer: A
Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.
The nurse is conducting a health interview with a patient named Salil. There is a language barrier, and no interpreter is available. Which of the following is the best example of an appropriate question for the nurse to ask in this situation?
- A. "Does Salil take medicine?"
- B. "Do you sterilize the bottles?"
- C. "Do you have nausea and vomiting?"
- D. "He has been taking his medicine, hasn't he?"
Correct Answer: A
Rationale: The correct answer is A: "Does Salil take medicine?" This is the best question because it is simple, direct, and focuses on gathering important medical information. It is clear and easy to understand even with a language barrier. Choice B is irrelevant and not related to the patient's health status. Choice C assumes symptoms without context. Choice D is inappropriate as it refers to the patient in the third person and includes a leading statement. Asking about medication directly is the most appropriate approach in this scenario.
A nurse is caring for a patient with a history of diabetes. The nurse should monitor for signs of which of the following complications?
- A. Hyperglycemia.
- B. Hypoglycemia.
- C. Dehydration.
- D. Hypotension.
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis. Hypoglycemia (B) is low blood sugar, dehydration (C) is not directly related to diabetes unless it causes hyperosmolar hyperglycemic state, and hypotension (D) is low blood pressure, which is not a common complication of diabetes. Regular monitoring for hyperglycemia helps in preventing diabetic complications.