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A nurse is caring for a patient hospitalized for the treatment of severe depression. Which of the following nursing approaches should be included in the patient's care plan? Which approach should be included for severe depression?
- A. Spend time sitting with the patient.
- B. Offer the patient choices of activities.
- C. Establish a patient relationship.
- D. Explore the truth of the patient's statements.
Correct Answer: A
Rationale: The correct answer is A: Spend time sitting with the patient. Spending time with the patient demonstrates empathy, support, and a willingness to listen, which are crucial for patients with severe depression. It helps build a therapeutic relationship and provides emotional comfort. Choice B focuses more on autonomy and may not address the patient's emotional needs. Choice C is important but is a broad concept that is encompassed by spending time with the patient. Choice D may come off as confrontational and potentially exacerbate the patient's distress.
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A nurse is caring for a patient who has a new prescription for enalapril. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for enalapril?
- A. Dry cough
- B. Weight loss
- C. Tinnitus
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Dry cough. Enalapril is an ACE inhibitor commonly associated with a side effect of a persistent dry cough due to increased bradykinin levels. The nurse should monitor the patient for this adverse effect as it can indicate drug intolerance. Choices B, C, and D are incorrect as weight loss, tinnitus, and hypoglycemia are not commonly associated with enalapril use. Weight gain may be more common due to fluid retention, tinnitus is not a known side effect, and hypoglycemia is not typically linked with enalapril.
A nurse is attending to a patient with a wound infection. What should the nurse do when collecting a wound-drainage specimen for culture? What should the nurse do for wound culture collection?
- A. Swab an area of skin away from the wound to identify the usual flora.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
- D. Include intact skin at the wound edges in the culture.
Correct Answer: C
Rationale: The correct answer is C: Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. This step is essential to ensure that the sample collected is not contaminated with external bacteria, which could lead to inaccurate results. By cleansing the wound with a sterile solution like saline, the nurse can remove debris and bacteria from the wound surface, increasing the likelihood of obtaining an accurate culture. Swabbing an area away from the wound (choice A) would not provide an accurate representation of the bacteria present in the wound. Irrigating the wound with an antiseptic (choice B) could potentially interfere with the culture results by killing the bacteria being tested for. Including intact skin at the wound edges in the culture (choice D) is unnecessary and could introduce contaminants. Overall, choice C is the most appropriate step to ensure a reliable wound culture.
A nurse is caring for a patient who attacked a friend and is now admitted to the psychiatric unit. Which of the following actions should the nurse take first? Which action should the nurse take first for an aggressive patient?
- A. Establish a patient relationship.
- B. Explore the truth of the patient's statements.
- C. Set behavioral limits for the patient.
- D. Explain to the patient that the behavior was unacceptable.
Correct Answer: C
Rationale: The correct answer is C: Set behavioral limits for the patient. This is the first action the nurse should take to ensure the safety of the patient and others. By setting clear boundaries and limits, the nurse can help manage the patient's aggressive behavior and prevent any further harm. Establishing a patient relationship (A) is important but secondary to ensuring immediate safety. Exploring the truth of the patient's statements (B) can be addressed once the aggressive behavior is under control. Explaining to the patient that the behavior was unacceptable (D) may not be effective in the heat of the moment and should come after setting limits.
A nurse notices a teenage patient with paraplegia in a wheelchair crying. What should the nurse's response be? What should the nurse respond to a crying teenage patient?
- A. I'll return later, and we can talk.
- B. Everything will be okay.
- C. Do you feel like crying helps?
- D. Would you like to be alone?
Correct Answer: A
Rationale: The correct answer is A: "I'll return later, and we can talk." This response acknowledges the patient's emotions, offers support, and opens the door for communication. It shows empathy and a willingness to engage with the patient. Choice B is dismissive and lacks empathy. Choice C may come across as invalidating the patient's feelings. Choice D may make the patient feel isolated. Overall, choice A is the most appropriate as it shows empathy, support, and a willingness to listen to the patient's concerns.
A nurse is assisting a healthcare provider with a sterile procedure and is preparing to pour solution onto a sterile piece of gauze. In what sequence should the nurse perform the following steps when pouring the sterile solution? In what sequence should the nurse pour sterile solution?
- A. Pick up the bottle with the label facing the palm.
- B. Pour the solution onto the gauze.
- C. Pour 1 to 2 mL into a receptacle.
- D. Perform hand hygiene.
- E. Place the bottle cap face-up on a clean surface.
- F. Remove the bottle cap.
Correct Answer: D,A,F,C,E,B
Rationale: The correct sequence is D, A, F, C, E, B.
1. Perform hand hygiene to ensure cleanliness.
2. Pick up the bottle with the label facing the palm to maintain sterility.
3. Remove the bottle cap to prepare for pouring.
4. Pour 1 to 2 mL into a receptacle to ensure proper amount.
5. Place the bottle cap face-up on a clean surface to prevent contamination.
6. Pour the solution onto the gauze for the sterile procedure to be completed.
Incorrect choices:
- G: It is not a step in the process of pouring sterile solution.
- The correct order ensures sterility, proper amount, and prevention of contamination.