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A nurse is caring for a patient who has a history of hypertension and reports a new onset of headaches, nausea, and dizziness. The nurse should be most concerned about which of the following?
- A. Hypertensive crisis.
- B. Migraine headache.
- C. Benign positional vertigo.
- D. Tension headache.
Correct Answer: A
Rationale: The correct answer is A: Hypertensive crisis. The nurse should be most concerned about this option because the patient has a history of hypertension and is experiencing new onset symptoms such as headaches, nausea, and dizziness, which could indicate a sudden and severe increase in blood pressure. This condition, if left untreated, can lead to serious complications such as stroke or heart attack.
Summary:
- B: Migraine headache is unlikely as the symptoms described are not typical of a migraine.
- C: Benign positional vertigo is unlikely as it does not explain the presence of headaches and nausea.
- D: Tension headache is less concerning compared to hypertensive crisis, given the patient's history of hypertension and the severity of symptoms.
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A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Respiratory failure.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD have impaired lung function, making them at risk for respiratory failure due to inadequate oxygenation. This can occur due to exacerbation of COPD, infections, or other factors. Monitoring for signs of respiratory distress is crucial.
A: Pneumonia - While patients with COPD are at higher risk for pneumonia due to impaired lung function, respiratory failure is a more immediate and critical complication to monitor for in this scenario.
C: Hypoglycemia - COPD does not directly increase the risk of hypoglycemia, so monitoring for this complication is not a priority in this case.
D: Hypertension - Although some patients with COPD may have hypertension, it is not a common complication directly related to COPD. Monitoring for respiratory failure is more essential in this situation.
A female nurse is interviewing a male patient who is close in age to the nurse. During the interview, the patient makes an overtly sexual comment. The nurse's best response would be:
- A. Stop that immediately!
- B. Oh, you are too funny. Let's keep going with the interview.
- C. Do you really think I'd be interested?
- D. It makes me uncomfortable when you talk that way. Please don't.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.
To assess affect, the nurse should ask the patient:
- A. How do you feel today?
- B. Would you please repeat the following words?
- C. Have these medications had any effect on your pain?
- D. Has this pain affected your ability to dress yourself?
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Asking "How do you feel today?" directly addresses the patient's emotional state.
2. Assessing affect involves understanding the patient's emotional response or mood.
3. This open-ended question encourages the patient to express their feelings.
4. It allows the nurse to gain insight into the patient's emotional well-being.
5. Options B, C, and D focus on different aspects like memory, medication effectiveness, and functional ability, not directly related to assessing affect.
When performing a physical assessment, the first technique the nurse will use is:
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: B
Rationale: The correct answer is B: Inspection. This is because visual observation is typically the initial step in a physical assessment to gather information about the patient's overall appearance, skin color, posture, and any obvious abnormalities. Palpation (A) involves touching and feeling for abnormalities, which usually follows inspection. Percussion (C) is the technique of tapping on the body to assess underlying structures, and auscultation (D) is listening to sounds produced by the body, both of which typically come after inspection and palpation. Inspecting the patient first allows the nurse to establish a baseline before moving on to more detailed assessment techniques.
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?
- A. Count the respirations, and call a physician immediately.
- B. Percuss the thorax bilaterally, noting any differences in percussion tones.
- C. Inspect the thorax for any masses and bleeding associated with respirations.
- D. Call for a chest x-ray examination, and wait for the results before beginning an assessment.
Correct Answer: B
Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest.
Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.