Nokea
A nurse is assessing a patient’s ethnohistory.Which question should the nurse ask?
- A. What language do you speak at home?
- B. How different is your life here from back home?
- C. Which caregivers do you seek when you are sick?
- D. How different is what we do from what your family does when you are sick?
Correct Answer: B
Rationale: The correct answer is B because it directly addresses the patient's ethnohistory by asking about the differences in their life here compared to back home. This question helps the nurse understand the patient's cultural background, beliefs, and practices. Option A focuses solely on language, which is not sufficient to understand ethnohistory. Option C inquires about caregivers during sickness, which is important but does not specifically relate to ethnohistory. Option D compares treatment approaches, which is relevant but doesn't explore the broader cultural context as effectively as option B.
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In determining malnourishment in a patient, which assessment finding is consistent with this disorder?
- A. Moist lips
- B. Pink conjunctivae
- C. Spoon-shaped nails
- D. Not easily plucked hair
Correct Answer: C
Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia).
Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency.
Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment.
Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
- A. Ewald
- B. Dobhoff
- C. Miller-Abbott
- D. Sengstaken-Blakemore
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach.
Summary of why the other choices are incorrect:
B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage.
C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage.
D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.
A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. In this scenario, a platelet count of 50,000/mcL indicates thrombocytopenia, which is a key component of HELLP syndrome. Low platelet count can lead to bleeding complications and is a critical indicator of the syndrome.
Choices B, C, and D are incorrect.
B: Liver enzyme levels within normal range do not necessarily indicate the presence of HELLP syndrome, as elevated liver enzymes are a hallmark feature of the syndrome.
C: Being negative for edema is not a reliable indicator of HELLP syndrome, as edema is a common finding in preeclampsia but not specific to HELLP syndrome.
D: No evidence of nausea or vomiting is not a specific sign of HELLP syndrome, as these
During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
- A. Ask the social worker to investigate alternative housing arrangements.
- B. Ask the social worker to investigate community support agencies.
- C. Encourage the patient to explore surgical corrections for the vision problem.
- D. Arrange for referral to a rehabilitation facility for vision training.
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently.
A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management.
B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management.
C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
- A. “I know I will need to have an abortion as soon as possible.”
- B. “Even though my test is positive, my baby might not be affected.”
- C. “My baby is certain to have AIDS and die within the first year of life.”
- D. “This pregnancy will probably decrease the chance that I will develop AIDS.”
Correct Answer: B
Rationale: The correct answer is B because it shows an understanding that being HIV-positive does not guarantee transmission to the baby. The statement acknowledges the possibility of the baby not being affected, which demonstrates awareness of the varying outcomes. Choice A is incorrect as it assumes abortion is the only option. Choice C is incorrect as it makes an extreme and inaccurate claim. Choice D is incorrect as pregnancy does not decrease the chance of developing AIDS.