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A nurse approaches a hospitalized poststroke patient from the patient’s left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse’s presence or voice. Which action should the nurse take first?
- A. Walk to the other side of the bed and try again
- B. Speak more loudly and clearly
- C. Wave his or her fingers in front of the patient’s face
- D. Use a picture to explain to the patient what the nurse is going to do.
Correct Answer: A
Rationale: Rationale:
1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit.
2. This step helps determine if the lack of response is due to a sensory issue.
3. It allows the nurse to rule out unilateral neglect or hemianopsia.
4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients.
Other Choices:
B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing.
C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits.
D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.
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An 83-year old client diagnosed with COPD has been receiving 1L of oxygen via nasal cannula. When the relatives visited, the sister of the client increased the oxygen to 7L per minute because she says that the client “looks like he is having difficulty getting air.” What should the nurse’s initial action be?
- A. Thank the client’s sister and continue to observe the client
- B. Immediately decrease the oxygen
- C. Notify the physician
- D. elevate client’s head and take her vital signs
Correct Answer: C
Rationale: The correct initial action for the nurse is to choose option C: Notify the physician. Increasing oxygen without a healthcare provider's order can be harmful, especially in COPD patients prone to retaining carbon dioxide. The nurse should communicate the situation to the physician to assess the client's condition and adjust the oxygen therapy appropriately. Option A is incorrect as it neglects the potential risks of high oxygen levels. Option B is incorrect as immediate decrease without proper assessment can be dangerous. Option D is not the priority when the client's oxygen therapy needs evaluation.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: The correct answer is D - Patency of airway and adequacy of respiration. This is the most important assessment during the acute stage of an unconscious patient like Mr. Franco because maintaining a clear airway and ensuring proper breathing are crucial for sustaining life. Without a patent airway and adequate respiration, the patient's oxygen supply could be compromised, leading to serious complications such as hypoxia or respiratory failure. Monitoring the airway and respiratory status takes precedence over other assessments in this scenario.
A: Level of awareness and response to pain - While important, assessing level of awareness and response to pain is secondary to ensuring a patent airway and adequate respiration in an unconscious patient.
B: Papillary reflexes and response to sensory stimuli - While these assessments provide valuable information about neurological function, they are not as critical as maintaining a clear airway and proper breathing in an unconscious patient.
C: Coherence and sense of hearing - Coherence and sense of hearing are not as vital as
Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: C
Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.
A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
- A. Onset of sporadic sexual activity at age 17
- B. Spontaneous abortion at age 19
- C. Pregnancy complicated with eclampsia at age 27
- D. Human papilloma virus infection at age 32
Correct Answer: D
Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV infection is a well-known risk factor for cervical cancer as certain strains of HPV can lead to cellular changes in the cervix that may progress to cancer. Here's the rationale:
1. HPV is a known risk factor: HPV is a sexually transmitted infection that is strongly linked to the development of cervical cancer.
2. Age of infection: The client's history of acquiring HPV at age 32 is significant as long-standing HPV infection increases the risk of cervical cancer.
3. Other choices are not directly linked: Choices A, B, and C are not directly associated with an increased risk of cervical cancer. Age of sexual activity onset, spontaneous abortion, and eclampsia are not established risk factors for cervical cancer.
Mr. Mendres asks Nurse Rose what causes peptic ulcer to develop. Nurse Rose responds that recent research indicates that peptic ulcers are the result of which of the following?
- A. genetic defect in the gastric mucosa
- B. helicobacter pylori infection
- C. high fat diet
- D. work related stress
Correct Answer: B
Rationale: The correct answer is B: helicobacter pylori infection. This bacterium is a major cause of peptic ulcers by weakening the protective mucous layer of the stomach and duodenum. Research has shown a strong association between H. pylori infection and peptic ulcer development. Genetic defects in the gastric mucosa (choice A) are not a proven cause of peptic ulcers. While a high-fat diet (choice C) can exacerbate symptoms, it is not the primary cause. Work-related stress (choice D) may exacerbate symptoms but is not a direct cause of peptic ulcers. Therefore, choice B is the most supported and logical answer based on current research findings.