Nokea
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
- A. Administering antibiotics as prescribed.
- B. Encouraging deep breathing and coughing exercises.
- C. Providing pain relief for chest discomfort.
- D. Monitoring oxygen saturation levels.
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
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A 35-year-old pregnant woman comes to the clinic for her monthly appointment. During assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:
- A. Keratosis.
- B. Mitoasma.
- C. Linea nigra.
- D. Linea gravida.
Correct Answer: C
Rationale: The correct answer is C: Linea nigra. This is a common finding during pregnancy due to hormonal changes causing hyperpigmentation on the abdomen. The other choices are incorrect because keratosis refers to a skin condition characterized by rough, scaly patches; melasma is a condition causing dark patches on the skin, often due to hormonal changes; and linea gravida is not a recognized term in dermatology. Therefore, based on the context of the patient being pregnant and presenting with hyperpigmentation on her face, the most likely finding would be Linea nigra, a dark line that runs from the navel to the pubic bone during pregnancy.
To which part of the assessment is information about who lives with a child, the method of disciplining, and support system related?
- A. Family history
- B. Review of systems
- C. Functional assessment
- D. Reason for seeking care
Correct Answer: C
Rationale: The correct answer is C: Functional assessment. This type of assessment focuses on understanding how an individual functions in their daily life. Information about who lives with a child, the method of disciplining, and support system directly relate to the child's functionality and overall well-being. Family history (A) typically refers to medical conditions in the family. Review of systems (B) involves examining different body systems for symptoms. Reason for seeking care (D) pertains to the specific reason why the child is seeking medical attention and does not encompass the broader aspects of the child's functioning.
Why is the concept of prevention essential in describing health?
- A. Disease can be prevented by treating the external environment.
- B. Most deaths among Canadians under age 65 are not preventable.
- C. Prevention places emphasis on the link between health and personal behaviour.
- D. The means to prevention is through treatment provided by primary health care practitioners.
Correct Answer: C
Rationale: The correct answer is C because prevention emphasizes the importance of personal behavior in maintaining health. It highlights the role of individual choices in preventing diseases and promoting well-being. A is incorrect because prevention focuses on proactive measures rather than treating external factors. B is incorrect as it contradicts the importance of prevention in reducing preventable deaths. D is incorrect because prevention is about avoiding health issues before they occur, not treating them after they have developed.
The nurse is interviewing a recent immigrant from Mexico. During the course of the interview, the man leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's. The nurse begins to feel uncomfortable with his proximity. Which of the following statements describes the most appropriate response by the nurse?
- A. Try to relax; this behaviour is culturally appropriate for this person.
- B. Discreetly move the chair back to a more comfortable distance, and then continue with the interview.
- C. These behaviours are indicative of sexual aggression, and the nurse should confront this person about them.
- D. The nurse should laugh but tell him that he or she is uncomfortable with the proximity and ask the person to move away.
Correct Answer: A
Rationale: The correct answer is A: "Try to relax; this behavior is culturally appropriate for this person." In Mexican culture, close proximity during conversations is common and signifies engagement and trust. By understanding cultural differences, the nurse can avoid misinterpreting the behavior. Moving the chair back (choice B) may be seen as rude. Assuming sexual aggression (choice C) without evidence is inappropriate. Laughing and asking to move away (choice D) may embarrass the individual. Understanding and respecting cultural norms is crucial in providing effective care.
A patient is experiencing dizziness, blurred vision, and nausea. The nurse should first assess the patient's:
- A. Electrolyte levels.
- B. Blood pressure.
- C. Blood glucose levels.
- D. Temperature and respiratory rate.
Correct Answer: B
Rationale: The correct answer is B, Blood pressure. Dizziness, blurred vision, and nausea can be symptoms of hypotension or hypertension. Assessing the patient's blood pressure first is crucial to determine if the symptoms are related to blood pressure fluctuations. Electrolyte levels (A) and blood glucose levels (C) may be assessed later but do not address the immediate concern. Temperature and respiratory rate (D) are important assessments but are not the priority in this scenario where cardiovascular status needs to be evaluated first.