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A nurse is assessing a patient's family history. Which of the following would be most relevant to include in the assessment?
- A. History of heart disease, cancer, and diabetes
- B. The patient's siblings' hobbies and interests
- C. The patient's father's occupation
- D. The patient's favorite sports team
Correct Answer: A
Rationale: The correct answer is A because a family history of heart disease, cancer, and diabetes can provide crucial information about potential genetic predispositions and health risks for the patient. This information helps the nurse assess the patient's risk factors and tailor preventative measures or interventions accordingly.
Choice B is incorrect as siblings' hobbies and interests are not relevant to the patient's medical history. Choice C is incorrect as the father's occupation does not directly impact the patient's health risks. Choice D is incorrect as the patient's favorite sports team is not relevant to assessing the patient's family history for health-related issues.
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A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?
- A. Ask the patient to take deep breaths
- B. Have the patient sit upright
- C. Examine for symmetry
- D. Ask the patient to lie flat and breathe normally
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients.
A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately.
B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds.
C: Examining for symmetry is important but not directly related to the optimal position for auscultation.
Which of the following questions would best assess a person's judgement?
- A. Do you feel that you are being watched, followed, or controlled?
- B. Tell me about what you plan to do once you are discharged from the hospital.
- C. What does the saying, "People in glass houses shouldn't throw stones' mean to you?
- D. What would you do if you found a stamped, addressed envelope on the sidewalk?
Correct Answer: B
Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.
A nurse is teaching a patient with asthma about proper inhaler use. Which of the following statements by the patient indicates the need for further education?
- A. I should hold my breath for 10 seconds after inhaling the medication.
- B. I should use my inhaler before exercise to prevent symptoms.
- C. I can use my inhaler every 30 minutes if I have trouble breathing.
- D. I should rinse my mouth after using my inhaler to prevent thrush.
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every 30 minutes for trouble breathing is not recommended. Overuse can lead to medication side effects and potential worsening of symptoms.
A: Holding breath after inhaling helps medication reach lungs.
B: Using inhaler before exercise can prevent exercise-induced symptoms.
D: Rinsing mouth prevents thrush, a common side effect of inhaled corticosteroids.
While auscultating for heart sounds, the nurse hears an unfamiliar sounWhat should the nurse do next?
- A. Document the findings on the patient's record.
- B. Wait 10 minutes, and auscultate the heart again.
- C. Ask another nurse to double-check the finding.
- D. Ask the patient to take deep breaths and check for changes in their physical condition.
Correct Answer: A
Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.
A nurse is caring for a patient with chronic asthma. The nurse should monitor the patient for which of the following complications of asthma?
- A. Hypoglycemia.
- B. Oxygen toxicity.
- C. Hyperkalemia.
- D. Respiratory failure.
Correct Answer: D
Rationale: The correct answer is D: Respiratory failure. In chronic asthma, persistent inflammation and airway remodeling can lead to worsening lung function and respiratory distress, ultimately resulting in respiratory failure. Monitoring for signs of respiratory distress such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.
A: Hypoglycemia is not a typical complication of asthma.
B: Oxygen toxicity is not a common complication in asthma management unless high concentrations of supplemental oxygen are administered for prolonged periods.
C: Hyperkalemia is not directly associated with asthma but may occur as a complication of certain asthma treatments or comorbid conditions.
Therefore, the priority complication to monitor in a patient with chronic asthma is respiratory failure due to the progressive nature of the disease and the potential for acute exacerbations.