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A nurse is collecting information from a client with dementia. The client’s daughter accompanies the client. Which of the following statements by the nurse would recognize the client’s value as an individual?
- A. “Can you tell me how long your father has been this way?”
- B. “Sarah, I have to go and read your father’s old charts before we talk.”
- C. “Mr. Koeppe, tell me what you do to take care of yourself.”
- D. “Mr. Koeppe, I know you can’t answer my questions, but it’s okay.”
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the client's value as an individual by directly addressing them and asking about their own self-care practices, which respects their autonomy and personhood. Choice A focuses on the client's father rather than the client themselves. Choice B addresses the daughter, not the client, and implies a lack of prioritization of the client's needs. Choice D is dismissive and does not recognize the client's capacity to communicate, undermining their dignity.
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Which of the following risk factors presents the greatest threat for respiratory disease?
- A. Smoking
- B. Exposure to radiation
- C. High-fat diet
- D. Alcohol consumption
Correct Answer: A
Rationale: The correct answer is A: Smoking. Smoking presents the greatest threat for respiratory disease due to the harmful chemicals in tobacco that can damage the lungs and lead to conditions like COPD and lung cancer. Smoking is a well-known risk factor for various respiratory issues. Exposure to radiation (B) can increase cancer risk but is not as directly linked to respiratory diseases. High-fat diet (C) may impact overall health but is not a primary risk factor for respiratory diseases. Alcohol consumption (D) can contribute to respiratory issues, but smoking is considered the most significant risk factor.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take to assess the severity of the latex allergy and determine appropriate interventions. By gathering more information about the reaction, the nurse can better understand the potential risks and provide safe care.
Summary of other choices:
A: Immediately placing the patient in isolation is unnecessary and not indicated based solely on the patient's latex allergy.
C: Proceeding to the termination phase of the interview is premature without fully assessing the patient's allergy.
D: Documenting the allergy is important but should not be the first action without assessing the reaction itself.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.
A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
- A. Administer pain medication every 4 hours as needed.
- B. Turn the patient every 2 hours, even hours. NursingStoreRN
- C. Monitor vital signs, especially rhythm.
- D. Keep the bed side rails up at all times.
Correct Answer: B
Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.
Mr Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse?
- A. Shampoo hair thoroughly to remove oil and dirt
- B. No special preparation is needed. Instruct the patient to keep his head still and stead
- C. Give a cleansing enema and give fluids until 8 AM
- D. Shave scalp and securely attach electrodes to it
Correct Answer: A
Rationale: The correct answer is A because shampooing the hair thoroughly helps remove oil and dirt, which can interfere with the CT scan results. By having clean hair, the scan can produce clearer images.
Choice B is incorrect because some preparation is needed for a CT scan, especially regarding cleanliness.
Choice C is incorrect as giving a cleansing enema and fluids until 8 AM is not necessary for a CT scan of the head.
Choice D is incorrect as shaving the scalp and attaching electrodes are not part of routine preparation for a CT scan.