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A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
- A. Where is the pain located?
- B. What causes the pain?
- C. Does it come and go?
- D. What does the pain feel like?
Correct Answer: A
Rationale: The correct answer is A because the "Where is the pain located?" question corresponds to the "P" component in the PQRST assessment, which stands for Provocative/Palliative factors. This question helps identify the specific location of the pain and what triggers or alleviates it. The other choices are incorrect because:
- B: "What causes the pain?" corresponds to the "Q" component (Quality of pain), focusing on the characteristics of the pain.
- C: "Does it come and go?" corresponds to the "R" component (Region/Radiation of pain), focusing on the pattern and radiation of the pain.
- D: "What does the pain feel like?" corresponds to the "S" component (Severity of pain), focusing on the intensity of the pain.
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Which of the following intravenous solutions is hypotonic?
- A. Normal saline
- B. Ringer’s lactate
- C. 0.45% saline
- D. 5% dextrose in normal saline A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET F
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell.
Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts.
5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?
- A. Assessment skills
- B. Nursing books
- C. Client’s records
- D. Supervisor’s advice
Correct Answer: A
Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.
A brain abscess is a collection of pus within the substance of the brain and is caused by:
- A. Direct invasion of the brain
- B. Spread of infection by other organs
- C. Spread infection from nearby sites
- D. All of the above mechanisms
Correct Answer: D
Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion occurs when bacteria enter the brain tissue directly, such as through trauma or surgery. Infections from other organs, like the lungs or heart, can spread through the bloodstream to the brain. Infections from nearby sites, such as the ears or sinuses, can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C individually do not cover all the possible causes of a brain abscess, making D the correct choice.
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
- A. Smoking
- B. Obesity
- C. Heavy alcohol consumption
- D. Saccharin consumption
Correct Answer: B
Rationale: The correct answer is B: Obesity. Obesity is a known risk factor for colon cancer as excess body fat, especially around the waist, can lead to inflammation and insulin resistance, increasing the likelihood of cancerous cell growth in the colon. Smoking (choice A) is more strongly associated with lung and other types of cancer, not specifically colon cancer. Heavy alcohol consumption (choice C) is linked to other types of cancer, such as liver and esophageal cancer, but not as strongly to colon cancer. Saccharin consumption (choice D) has not been definitively linked to an increased risk of colon cancer.
or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. “Client verbalizes feelings of anxiety.”
- B. “Client doesn’t guess at prognosis.”
- C. “Client uses any effective method to reduce tension.”
- D. “Client stops seeking information.”
Correct Answer: A
Rationale: The correct answer is A because it reflects a measurable and client-centered outcome. Verbalizing feelings of anxiety indicates the client is acknowledging and addressing their emotions, which is essential in managing anxiety. Choice B is incorrect as it focuses on avoidance rather than expression of emotions. Choice C is incorrect as it doesn't specify the use of appropriate coping mechanisms. Choice D is incorrect as it suggests avoidance of seeking information, which may hinder the client's understanding and coping with the diagnosis.