Nokea
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.
You may also like to solve these questions
A pregnant client with hypertension and cardiac dysrhythmias is admitted to the hospital. Which of the following imbalances should the nurse check for?
- A. Metabolic acidosis
- B. Hypernatremia
- C. Hypomagnesemia
- D. Hypercalcemia
Correct Answer: C
Rationale: The correct answer is C: Hypomagnesemia.
1. Hypertension and cardiac dysrhythmias can be exacerbated by low magnesium levels.
2. Magnesium plays a crucial role in maintaining normal heart rhythm and blood pressure.
3. Hypomagnesemia can lead to cardiac arrhythmias and worsen hypertension.
4. Metabolic acidosis (A) is not directly related to hypertension and dysrhythmias.
5. Hypernatremia (B) and hypercalcemia (D) are less likely to be associated with cardiac issues in this context.
In summary, checking for hypomagnesemia is essential due to its direct impact on the client's hypertension and cardiac dysrhythmias.
In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?
- A. Etiology
- B. Problem
- C. Defining characteristics
- D. Client need
Correct Answer: A
Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors that lead to the identified problem. In this case, the presence of a large scar over the left side of the face is the underlying cause of the disturbed self-esteem. It directly influences the client's self-perception and self-worth. The problem (B) is the disturbed self-esteem itself, not the scar. Defining characteristics (C) are the signs and symptoms that support the nursing diagnosis. Client need (D) is a broader concept that encompasses the overall needs of the client, whereas etiology specifically focuses on the cause of the problem.
The cause of death of most AIDS patients who develop multiple opportunistic infections is/are the following: a.Weakened immune system impairs response to therapy
- A. AH of these (a, b, c)
- B. Weakened immune system impairs resistance to infection
- C. Infection cannot be treated effectively
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Most AIDS patients with multiple opportunistic infections die due to a weakened immune system impairing response to therapy. When the immune system is compromised, the body struggles to fight off infections effectively, even with treatment. This results in the infections becoming more severe and ultimately leading to death.
Summary of Other Choices:
B: Weakened immune system impairs resistance to infection - While this is true, it doesn’t directly address the cause of death in AIDS patients with multiple infections.
C: Infection cannot be treated effectively - This is not entirely accurate as infections can be treated, but the weakened immune system hinders the response to treatment.
Overall, Choice A is the most accurate as it directly links the weakened immune system to the inability to respond effectively to therapy, leading to fatal outcomes.
The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
- A. Assisting with activities of daily living
- B. Counseling about respite care options
- C. Teaching range-of-motion exercises
- D. Consulting with a social worker
Correct Answer: B
Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout.
A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain.
C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain.
D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.
Minda, a 65-year old female has been admitted with a left hemisphere stroke. Which behavioral change would the nurse expect to find upon assessment?
- A. impulsive, unsafe activity
- B. motor deficits on the right eye
- C. motor deficits on the left side of the body
- D. error in word choices
Correct Answer: D
Rationale: The correct answer is D: error in word choices. In left hemisphere stroke, language and speech centers are usually affected, leading to aphasia. This results in errors in word choices, difficulty expressing thoughts, and understanding language. Impulsivity and unsafe activities (choice A) are more commonly associated with frontal lobe damage. Motor deficits on the right eye (choice B) and left side of the body (choice C) are typical in strokes affecting the motor cortex, which is located in the contralateral hemisphere.