Nokea
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
- A. breath sounds
- B. blood pressure
- C. capillary refill
- D. butterfly rash
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct:
1. Blood pressure is vital in this scenario due to prednisone discontinuation.
2. Abruptly stopping prednisone can lead to adrenal insufficiency.
3. Adrenal insufficiency can cause hypotension, a life-threatening condition.
4. Monitoring blood pressure can help detect and manage potential complications.
Summary of other choices:
A: Breath sounds – Important but not the priority in this specific situation.
C: Capillary refill – Useful for assessing circulation but not urgent in this context.
D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
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. A female client experiences trauma to her urinary tract during an accident. Which of the ff factors should the nurse consider while assessing the client?
- A. Assessment of sexual habits
- B. Assessment and recognition of abnormal findings
- C. Assessment of allergies to seafood
- D. Assessment of insurance coverage
Correct Answer: B
Rationale: The correct answer is B: Assessment and recognition of abnormal findings. This is crucial as trauma to the urinary tract can lead to various complications such as urinary retention, infection, or injury to surrounding structures. By assessing and recognizing abnormal findings, the nurse can promptly identify any issues and initiate appropriate interventions.
Choice A (Assessment of sexual habits) may be important for assessing risk factors for urinary tract trauma, but it is not directly related to assessing the client's current condition post-accident. Choice C (Assessment of allergies to seafood) is irrelevant in this scenario as it does not impact the assessment of urinary tract trauma. Choice D (Assessment of insurance coverage) is not a priority when assessing a client's immediate health status post-accident.
A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)
- A. Includes seven domains for level 1
- B. Uses an easy 3-point Likert scale
- C. Adds objectivity to judging a patient’s progress
- D. Allows choice in which interventions to choose
Correct Answer: C
Rationale: The correct answer is C because Nursing Outcomes Classification adds objectivity to judging a patient's progress by providing standardized criteria for assessing outcomes. This helps in evaluating the effectiveness of interventions and tracking improvements accurately. Other choices are incorrect: A is wrong because Nursing Outcomes Classification includes 7 domains but not necessarily for level 1; B is incorrect as it uses a 5-point Likert scale, not a 3-point scale; and D is inaccurate because Nursing Outcomes Classification guides the selection of interventions based on the identified outcomes, not allowing complete freedom in choosing interventions.
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
- A. orthopnea
- B. fever
- C. weight loss
- D. calf pain A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET O
Correct Answer: A
Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat.
Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe.
Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection.
Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF.
Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF.
Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.
Which of the following terms indicates that the patient has a hearing loss caused by aging?
- A. Otoplasty
- B. Presbycusis
- C. Otalgia
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.