Nokea
A nurse is assessing a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Administering pain medication as needed.
- B. Encouraging deep breathing and coughing exercises.
- C. Monitoring for signs of infection.
- D. Providing wound care and dressing changes.
Correct Answer: B
Rationale: The correct answer is B because deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia after abdominal surgery. By promoting lung expansion and clearing secretions, these exercises enhance oxygenation and prevent respiratory issues. Administering pain medication (A) is important but not the priority. Monitoring for infection (C) and providing wound care (D) are also crucial but come after ensuring respiratory function.
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The public's concept of health has changed since the 1950s. Which of the following statements most accurately describes this change?
- A. Lifestyle, personal habits, exercise, and nutrition are essential to health.
- B. Assessment of health is critical to identifying disease-causing pathogens.
- C. Accurate diagnosis and treatment by a physician are essential for all health care.
- D. An individual is considered healthy when signs and symptoms of disease have been eliminated.
Correct Answer: A
Rationale: The correct answer is A because it reflects the shift towards a holistic view of health focusing on preventive measures and lifestyle choices. In the 1950s, the emphasis was more on treating diseases rather than preventing them through healthy habits. Choice B is incorrect as it only focuses on identifying pathogens, not overall health. Choice C is incorrect because it emphasizes physician-centered healthcare rather than individual responsibility. Choice D is incorrect as it only considers the absence of symptoms, not overall well-being. Therefore, A is the best choice as it aligns with the modern understanding of health promotion and disease prevention.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse would expect to find which of the following?
- A. Anasarca.
- B. Scleroderma.
- C. Pedal erythema.
- D. Clubbing of the nails.
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
- A. Peripheral vascular disease.
- B. Deep vein thrombosis.
- C. Cellulitis.
- D. Skin cancer.
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.
What is the correct interpretation of a drumlike sound heard during percussion of the abdomen?
- A. Constipation
- B. Air-filled areas
- C. The presence of a tumor
- D. The presence of dense organs
Correct Answer: B
Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination.
Incorrect Answers:
A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention.
C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion.
D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.
During an interview with a patient, at which distance would the nurse expect that most of the interview will take place?
- A. 1 m
- B. 1.5 m
- C. 2 m
- D. 3 m
Correct Answer: B
Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.