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A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following interventions?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Administering an oral hypoglycemic agent.
- D. Monitoring the patient's blood pressure.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.
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The nurse is performing a health assessment on a 16-year-old girl, who has been brought to the clinic by her parents. Which of the following instructions would be appropriate for the parents before the interview begins?
- A. "Please stay with your daughter during the interview; you can answer for her if she is not able to."
- B. "It would help to interview the three of you together."
- C. "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?"
- D. "While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?"
Correct Answer: D
Rationale: The correct answer is D because it respects the girl's privacy and allows her to speak freely without parental influence. By asking the parents to step out, the nurse creates a safe space for the girl to discuss any sensitive issues. Choice A may inhibit the girl's honest communication. Choice B risks the parents dominating the conversation. Choice C may make the girl uncomfortable discussing personal matters in front of her parents.
Which of the following statements reflects a component of spirituality?
- A. It is a belief in the worship of a higher power within an organization.
- B. It involves attendance at a specific church, synagogue, temple, mosque, or house of worship.
- C. It is central to the human experience as a person searches for meaning in life.
- D. It is closely tied to a person's ethnic, social, cultural, and historical background.
Correct Answer: C
Rationale: The correct answer is C because spirituality is a personal and intrinsic search for meaning and purpose in life, which is central to the human experience. This definition aligns with the concept of spirituality as a journey of self-discovery and reflection, independent of organized religion or cultural background.
Explanation for why other choices are incorrect:
A: Worshiping a higher power within an organization implies a religious practice rather than spirituality, which is more individualistic and introspective.
B: Attendance at a specific house of worship is a religious practice, not necessarily reflective of spirituality, which can exist outside formal religious institutions.
D: While spirituality can be influenced by cultural background, it is not solely tied to it, as it transcends social, ethnic, and historical boundaries.
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
- A. Peripheral vascular disease.
- B. Deep vein thrombosis.
- C. Cellulitis.
- D. Skin cancer.
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.
A nurse is assessing a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Administering pain medication as needed.
- B. Encouraging deep breathing and coughing exercises.
- C. Monitoring for signs of infection.
- D. Providing wound care and dressing changes.
Correct Answer: B
Rationale: The correct answer is B because deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia after abdominal surgery. By promoting lung expansion and clearing secretions, these exercises enhance oxygenation and prevent respiratory issues. Administering pain medication (A) is important but not the priority. Monitoring for infection (C) and providing wound care (D) are also crucial but come after ensuring respiratory function.
A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train.' What is the best way for the nurse to communicate with this patient?
- A. Use speech because he will understand even if the nurse cannot understand him.
- B. Abandon all attempts to communicate with him. His aphasia is irreversible.
- C. Give him a pencil and paper because reading and writing abilities will not be impaired.
- D. Support his efforts to communicate, and use pantomime and gestures to communicate when possible.
Correct Answer: D
Rationale: The correct answer is D because the patient is showing signs of expressive aphasia, where they have difficulty with verbal expression. By supporting his efforts to communicate and using pantomime and gestures, the nurse can help bridge the communication gap and facilitate understanding. This approach acknowledges the patient's drive to communicate and helps him convey his thoughts effectively.
Option A is incorrect because although the patient may understand, the nurse needs to adapt the communication method to support the patient's expressive difficulties. Option B is incorrect as abandoning communication efforts would be detrimental to the patient's well-being and recovery. Option C is incorrect as the patient's ability to read and write may also be impaired due to the stroke, making this method less effective than using gestures and pantomime.