Nokea
A nurse is caring for a patient with a history of stroke. The nurse should prioritize which of the following interventions?
- A. Encouraging mobility to prevent pressure ulcers.
- B. Monitoring for signs of deep vein thrombosis (DVT).
- C. Administering antihypertensive medication.
- D. Providing psychological support.
Correct Answer: B
Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility.
Step 2: Monitoring for DVT signs is crucial for early detection and prevention.
Step 3: Prompt intervention can prevent life-threatening complications.
Step 4: Encouraging mobility (Choice A) is important but not the priority.
Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority.
Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.
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Which food should a client with hypercholesterolemia decrease in their diet?
- A. broiled catfish
- B. hamburgers
- C. wheat bread
- D. fresh apples
Correct Answer: B
Rationale: The correct answer is B: hamburgers. Clients with hypercholesterolemia should decrease their intake of foods high in saturated fats, like hamburgers. Saturated fats can raise LDL cholesterol levels. Broiled catfish (A) is a lean protein option, wheat bread (C) is a good source of fiber, and fresh apples (D) are a healthy fruit choice. Hamburgers (B) typically contain high levels of saturated fats from red meat and processed ingredients, making them a less ideal choice for individuals with high cholesterol.
What does the Health Insurance Portability and Accountability Act (HIPAA) regulate?
- A. Who will provide client care
- B. Privacy of information
- C. How insurance information is obtained
- D. Where a chart can be stored
Correct Answer: B
Rationale: The correct answer is B because HIPAA regulates the privacy and security of protected health information. This includes how healthcare providers, insurers, and other entities handle and safeguard patient information to ensure confidentiality. Choice A is incorrect as HIPAA does not dictate who provides client care. Choice C is incorrect as HIPAA focuses on the protection of health information, not how insurance information is obtained. Choice D is incorrect as HIPAA does not specify where a chart can be stored, but rather how the information within it is protected.
What is the most important intervention for a client with acute myocardial infarction (MI)?
- A. Administer aspirin
- B. Administer oxygen
- C. Administer morphine
- D. Administer nitroglycerin
Correct Answer: A
Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.
A nurse is assessing a patient's breath sounds and notes that the patient has a wheeze. This is most likely indicative of:
- A. Pneumonia.
- B. Asthma.
- C. Pulmonary embolism.
- D. Pleural effusion.
Correct Answer: B
Rationale: The correct answer is B: Asthma. Wheezing is a high-pitched whistling sound heard during expiration caused by narrowed airways in conditions like asthma. Pneumonia (A) typically presents with crackles, not wheezes. Pulmonary embolism (C) may cause sudden chest pain and shortness of breath but not wheezing. Pleural effusion (D) results in decreased breath sounds, not wheezes.
During a follow-up visit, the nurse discovers that the patient has not been taking his insulin regularly. The nurse asks, "Why haven't you taken your insulin?' Which of the following is an appropriate evaluation of this question?
- A. It may put the patient on the defensive.
- B. It is an innocent attempt to get information.
- C. It would have been better to discuss this with his wife.
- D. It is the best way to discover the reasons for his behaviour.
Correct Answer: A
Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship.
Explanation of other choices:
B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue.
C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy.
D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.