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A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
- A. Breathing, pain, sleep
- B. Breathing, sleep, pain
- C. Sleep, breathing, pain
- D. Sleep, pain, breathing
Correct Answer: A
Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first.
Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.
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A 59-year-old patient tells the nurse that he is in the clinic to "check up on his ulcerative colitis." He has been having "black stools" in the last 24 hours. How would the nurse document his reason for seeking care?
- A. J.M. is a 59-year-old male here for "ulcerative colitis."
- B. J.M. came into the clinic complaining of black stools in the past 24 hours.
- C. J.M., a 59-year-old male, states he has ulcerative colitis and wants to have it checked up.
- D. J.M. is a 59-year-old male here for having "black stools" in the past 24 hours.
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the patient's chief complaint of having black stools in the last 24 hours, which is a concerning symptom suggestive of gastrointestinal bleeding. This documentation is specific and focused on the reason for seeking care, prioritizing the urgent nature of the symptom.
Choice A is incorrect because it does not mention the presenting symptom of black stools. Choice B is incorrect as it does not directly state the reason for seeking care. Choice C is incorrect as it focuses on the patient's self-diagnosis of ulcerative colitis rather than the current concerning symptom of black stools.
Which quadrant of the abdomen is tender in suspected appendicitis?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.
Critique the following statement made by the nurse: "I know it may be hard, but you should do what the doctor ordered because he/she is the expert in this field.'
- A. This statement is inappropriate because it shows the nurse's bias.
- B. This statement is appropriate because members of the health care team are experts in the area of patient care.
- C. This type of statement creates dependency and inferiority in the patient and is best avoided in an interview situation.
- D. At times, it is necessary to use authority statements when dealing with patients, especially when they are undecided about an issue.
Correct Answer: C
Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making.
The other choices are incorrect because:
A: This choice focuses on bias, which is not the main issue at hand in this scenario.
B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience.
D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.
What should the nurse monitor when caring for a client receiving anticoagulant therapy?
- A. Monitor platelet count
- B. Monitor INR levels
- C. Monitor bleeding
- D. Monitor renal function
Correct Answer: B
Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications.
Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy.
Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy.
Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.
What is the priority nursing action for a client with a suspected stroke?
- A. Administer oxygen
- B. Administer aspirin
- C. Administer thrombolytics
- D. Place the client in a supine position
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.