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A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.
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The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
- A. No change in the condition
- B. An improvement of the weakness
- C. Complaints of muscle spasms
- D. A temporary worsening of the condition
Correct Answer: B
Rationale: The correct answer is B: An improvement of the weakness. Edrophonium is a short-acting cholinesterase inhibitor that helps differentiate between myasthenic and cholinergic crises in myasthenia gravis. In cholinergic crisis, there is an overdose of cholinesterase inhibitors leading to excessive acetylcholine at the neuromuscular junction, causing muscle weakness. Administering edrophonium will temporarily improve muscle weakness in cholinergic crisis due to the increased availability of acetylcholine. The other choices are incorrect because: A: No change suggests the client is not in cholinergic crisis. C: Complaints of muscle spasms are more indicative of myasthenic crisis. D: A temporary worsening of the condition is not expected in cholinergic crisis.
The physician orders furosemide (Lasix) 40 mg IV STAT for an acutely fluid-overloaded patient. Why was the IV route likely chosen?
- A. Furosemide can be administered only by the IV route.
- B. IV is the route of choice for rapid administration.
- C. IV dosing is more accurate.
- D. IV furosemide has a fewer side effects than oral.
Correct Answer: B
Rationale: The correct answer is B: IV is the route of choice for rapid administration. IV route allows for quick onset of action, crucial in acutely fluid-overloaded patients needing immediate diuresis. Option A is incorrect as furosemide can be given orally too. Option C is less relevant in this urgent situation where speed is key. Option D is also incorrect as the side effects are not determined by route of administration.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. This ensures patient-centered care and respects the patient's autonomy. Speaking only to the daughter may undermine the patient's dignity and may lead to incomplete information gathering. Choices A, C, and D are incorrect as they are appropriate nursing communication techniques that facilitate rapport-building and active listening with the patient. Making eye contact, leaning forward, and nodding are all positive non-verbal cues that show engagement and attentiveness to the patient, promoting effective communication and building trust.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should always prioritize communication with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter could undermine the patient's autonomy and right to be involved in their care. It is important for the nurse to directly address the patient to gather accurate information and ensure patient-centered care. Making eye contact (A), leaning forward (C), and nodding periodically (D) are all appropriate communication techniques that show attentiveness and engagement with the patient, which are crucial in building rapport and trust.
A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?
- A. Perform the task for the patient
- B. Tell the patient not to worry about it
- C. Break the task down into simple steps
- D. Have another patient demonstrate how to perform the task
Correct Answer: C
Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion.
Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.