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A nurse exchanges information with the oncomingnurse about a patient’s care. Which action did the nurse complete?
- A. A verbal report
- B. An electronic record entry
- C. A referral
- D. An acuity rating
Correct Answer: A
Rationale: The correct answer is A: A verbal report. This is because exchanging information verbally between nurses allows for real-time communication, ensuring important details are accurately conveyed. Electronic record entry (B) involves documenting information in the patient's record but does not involve direct communication. Referral (C) refers to transferring the patient's care to another healthcare provider. Acuity rating (D) is a tool used to determine the severity of a patient's condition and does not involve exchanging information between nurses.
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A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition?
- A. Exostoses
- B. Otalgia
- C. Sensorineural hearing loss
- D. Presbycusis
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. This type of hearing loss is caused by damage to the inner ear or auditory nerve (cranial nerve VIII). Exostoses (A) are bony growths in the ear canal, not related to cranial nerve VIII. Otalgia (B) refers to ear pain, not hearing loss. Presbycusis (D) is age-related hearing loss, not specifically related to damage of the end organ for hearing or cranial nerve VIII. Therefore, C is the most appropriate term to describe the given condition.
A smiling patient angrily states, “I will notcough and deep breathe.” How will the nurse interpret this finding?
- A. The patient’s denotative meaning is wrong.
- B. The patient’s personal space was violated.
- C. The patient’s affect is inappropriate.
- D. The patient’s vocabulary is poor.
Correct Answer: C
Rationale: The correct answer is C because the patient's affect, which refers to their emotional expression, is inappropriate. The patient is smiling while expressing anger, which is a contradiction. This inconsistency indicates a possible underlying issue such as emotional distress or confusion. Choice A is incorrect because the issue is not about the patient's understanding of the term "cough and deep breathe." Choice B is incorrect as there is no mention of personal space violation. Choice D is incorrect as the issue is not related to the patient's vocabulary but rather their emotional expression.
A patient with Parkinsons disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond?
- A. Its important to drink plenty of fluids while youre taking laxatives.
- B. Make sure that you supplement your laxatives with a nutritious diet.
- C. Lets explore other options, because laxatives can have side effects and create dependency.
- D. You should ideally be using herbal remedies rather than medications to promote bowel function.
Correct Answer: C
Rationale: The correct answer is C: Lets explore other options, because laxatives can have side effects and create dependency. The rationale for this is that while laxatives provide temporary relief for constipation, using them long-term can lead to dependency, electrolyte imbalances, and other side effects. The nurse should address the root cause of constipation and explore alternative strategies such as dietary changes, increased fluid intake, exercise, and bowel training. Choices A and B focus on supportive measures rather than addressing the issue of potential dependency on laxatives. Choice D suggests herbal remedies without considering the individual's specific condition and medical history.
A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patients complaint?
- A. These pains are an expected finding during the first few weeks of recovery.
- B. The patients complaints are suggestive of a postoperative infection.
- C. The patient may have experienced a spontaneous rupture of the tympanic membrane.
- D. The patients surgery may have been unsuccessful.
Correct Answer: A
Rationale: The correct answer is A. Postoperative day 6 following tympanoplasty and mastoidectomy is still within the early phase of recovery, where occasional sharp, shooting pains in the affected ear can be expected due to the healing process. Here's a step-by-step rationale:
1. Timing: It is only day 6 post-surgery, so it is normal to experience some pain as part of the healing process.
2. Nature of pain: Sharp, shooting pains are common post-surgery due to tissue healing and nerve regeneration.
3. Lack of other symptoms: The patient did not report any other concerning symptoms like fever or discharge, which would be more indicative of an infection.
4. Unlikely complications: Spontaneous rupture of the tympanic membrane or unsuccessful surgery would typically present with more severe and consistent symptoms.
Summary:
- B: Unlikely as there are no other signs of infection.
- C: Unlikely as the pain is described as occasional and sharp.
- D:
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.
- A. Current medication regimen
- B. Identification of patients support system
- C. Immune system function
- D. Genetic risk factors for HIV E) History of sexual practices Chapter 37: Allergies: Terminologies, Causes of Allergic reactions: Causes, skin testing, labs, Emergency care, Hereditary angioedema, Latex allergy, Allergic rhinitis
Correct Answer: A
Rationale: The correct answer is A: Current medication regimen. In the admission assessment of a patient with AIDS, it is crucial to assess the patient's current medication regimen to ensure proper management of the condition. This includes antiretroviral therapy, prophylactic medications, and any other medications the patient may be taking to manage comorbidities. Understanding the medications the patient is currently taking allows the nurse to assess for potential drug interactions, side effects, and adherence to the treatment plan. This information is essential for providing safe and effective care for the patient.
Choice B: Identification of patients support system is important but not a specific component of the comprehensive assessment for a patient with AIDS.
Choice C: Immune system function is a relevant aspect in a patient with AIDS, but it is not typically assessed in the admission assessment as it requires specialized testing.
Choice D: Genetic risk factors for HIV are not typically assessed in the admission assessment of a patient with AIDS as the focus is on the current condition and management