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A nurse is caring for a patient who has had diarrheafor the past week. Which additional assessment finding will the nurse expect?
- A. Distended abdomen
- B. Decreased skin turgor
- C. Increased energy levels
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss and dehydration, causing a decrease in skin turgor. Assessing skin turgor by gently pinching the skin on the patient's forearm is important to determine hydration status. A: Distended abdomen is more indicative of possible bowel obstruction or fluid accumulation, not specifically related to diarrhea. C: Increased energy levels are unlikely as diarrhea typically causes fatigue and weakness due to electrolyte imbalance. D: Elevated blood pressure is not a typical finding with diarrhea unless there are other underlying medical conditions.
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A hospice nurse is well aware of how difficult it is to deal with others pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?
- A. Inefficiency in the provision of care
- B. Excessive weight gain
- C. Emotional exhaustion
- D. Social withdrawal
Correct Answer: C
Rationale: The correct answer is C: Emotional exhaustion. Dealing with others' pain daily can lead to burnout and emotional exhaustion for the nurse. This can result in decreased empathy and effectiveness in providing care. Healthy practices such as self-care, setting boundaries, and seeking support can help prevent emotional exhaustion.
Choice A: Inefficiency in the provision of care is incorrect because emotional exhaustion may affect the quality of care but does not necessarily lead to inefficiency.
Choice B: Excessive weight gain is incorrect as it is not directly related to the emotional toll of dealing with others' pain.
Choice D: Social withdrawal is incorrect as it is a potential outcome of emotional exhaustion but not the primary concern in this scenario.
A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using?
- A. Nonjudgmental
- B. Socializing
- C. Narrative
- D. SBAR
Correct Answer: C
Rationale: The correct answer is C: Narrative. The nurse is using a narrative interaction by asking the patient to share a personal story. This helps the patient express their experiences, emotions, and perspectives, promoting a deeper understanding of their care needs. A: Nonjudgmental is incorrect as it focuses on avoiding biases. B: Socializing is incorrect as it implies casual conversation. D: SBAR is incorrect as it stands for Situation, Background, Assessment, and Recommendation, used for concise communication in healthcare settings.
The nurse is teaching a health class about thegastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients?
- A. Ileum
- B. Cecum
- C. Stomach
- D. Duodenum
Correct Answer: D
Rationale: The correct answer is D: Duodenum. The duodenum is the first part of the small intestine where most of the digestion and absorption of nutrients occurs. It receives partially digested food from the stomach and mixes it with bile and pancreatic enzymes to break down nutrients. The villi in the duodenum increase the surface area for absorption. The other choices (A: Ileum, B: Cecum, C: Stomach) are incorrect because the ileum and cecum are parts of the small intestine where some absorption occurs but not as much as in the duodenum. The stomach primarily digests food and does not absorb many nutrients.
How will the nurse classify this finding?
- A. Normal weight
- B. Underweight
- C. Overweight
- D. Obese
Correct Answer: D
Rationale: The correct answer is D: Obese. This classification is based on the Body Mass Index (BMI) calculation, which takes into account weight and height. A BMI above 30 is considered obese, indicating excess body fat. Other choices are incorrect because they do not align with the BMI criteria for obesity. Choice A is incorrect as normal weight falls within a specific BMI range. Choice B is incorrect for individuals with a BMI below the normal range. Choice C is incorrect for individuals with a BMI between the overweight and obese categories.
A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The patient has asked if she will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this patient most likely undergo?
- A. Lymphadenectomy
- B. Needle biopsy
- C. Open biopsy
- D. Sentinel node biopsy
Correct Answer: D
Rationale: The correct answer is D: Sentinel node biopsy. This procedure involves identifying and removing the sentinel lymph node(s) which is the first lymph node(s) that cancer cells are likely to spread to from the primary tumor. This method helps determine if cancer has spread beyond the primary site without the need for a full axillary lymph node dissection. It is less invasive, has fewer side effects, and provides accurate staging information. Lymphadenectomy (A) refers to the removal of multiple lymph nodes, which is more extensive than necessary in this case. Needle biopsy (B) and open biopsy (C) are not specific to lymph node evaluation and do not provide accurate staging information for breast cancer.