Nokea
A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
- A. Verbal teaching in short sessions throughout the day
- B. Provide a pre-operative booklet in Braille
- C. Provide an audio recording for the client
- D. Have the blind patient's family member assist with the instruction
Correct Answer: A
Rationale: For a blind patient scheduled for surgery the following morning, the best teaching strategy would be verbal teaching in short sessions throughout the day. Providing information in smaller amounts makes it easier to retain, and one-on-one teaching is most effective. Choice B, providing a pre-operative booklet in Braille, may not be as practical for last-minute teaching. Choice C, providing an audio recording, may not allow for immediate interaction and clarification. Choice D, having a family member instruct the patient, may not ensure the accuracy and clarity of the information provided.
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Which type of cells secrete insulin?
- A. alpha cells
- B. beta cells
- C. CD4 cells
- D. helper cells
Correct Answer: B
Rationale: Beta cells are responsible for secreting insulin. Insulin is produced by beta cells in the pancreas and plays a crucial role in regulating blood sugar levels. Alpha cells secrete glucagon, not insulin (Choice A). CD4 cells are a type of immune cell that helps coordinate the immune response (Choice C). Helper cells are a type of immune cell that aids in activating other immune cells (Choice D). Therefore, the correct answer is beta cells.
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to hospitalization
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and joint pain
Correct Answer: C
Rationale: Monitoring Jackie's cardiac status is of the highest priority in a patient with rheumatic fever. Rheumatic fever can lead to permanent cardiac damage, making it crucial to closely monitor the heart. Assessing for signs of carditis, such as murmurs or other cardiac symptoms, is essential. The second priority is evaluating joint symptoms for the presence of polyarthritis and pain, which are common manifestations of rheumatic fever. While assessing Jackie's response to hospitalization is important for her emotional well-being, it is not the highest priority. The presence of a macular rash, although relevant, is not as high a priority as monitoring cardiac status or assessing joint symptoms.
A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
- A. pleurisy.
- B. pleural effusion.
- C. atelectasis.
- D. tuberculosis.
Correct Answer: A
Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by an abrupt onset of pain. Symptoms of pleurisy include sudden sharp, stabbing pain that is usually unilateral and localized to a specific portion of the chest. The pain can be exacerbated by deep breathing. In contrast, pleural effusion is characterized by fluid accumulation in the pleural space, not sharp pain. Atelectasis involves collapse or closure of a lung leading to reduced gas exchange, but it does not typically present with sharp, stabbing pain. Tuberculosis is a bacterial infection that can affect the lungs but does not typically manifest with sudden sharp pain exacerbated by deep breathing.
A nurse is instructing a patient about the warning signs of Digitalis side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?
- A. Seizures
- B. Muscle weakness
- C. Depression
- D. Anxiety
Correct Answer: B
Rationale: The correct answer is 'Muscle weakness.' Palpitations and muscle weakness are commonly associated with excessive levels of Digitalis. Seizures, depression, and anxiety are not typically linked to Digitalis toxicity. Seizures could be more related to other medications or conditions, while depression and anxiety are not commonly reported side effects of Digitalis.
When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?
- A. Allow her to grieve by herself.
- B. Tell her to go ahead and cry, after all, your husband’s pretty bad off.
- C. Tell her you realize how upset she is, but you don’t want to talk about it now.
- D. Approach her, offering tissues, and encourage her to verbalize her feelings
Correct Answer: D
Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions. Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.