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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: Where is the pain located? This matches with the "Location" component of the PQRST. This question helps determine the specific area where the pain is occurring, providing crucial information for diagnosis and treatment. This step is important in identifying potential underlying issues related to the pain.
Summary of other choices:
B: What causes the pain? - This question relates to the "Provocation/Palliation" component, not the location.
C: Does it come and go? - This question corresponds to the "Quality" component, focusing on the characteristics of the pain.
D: What does the pain feel like? - This question aligns with the "Severity" component, concentrating on the intensity of the pain.
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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A because the first phase of the nursing process is assessment, where the nurse gathers comprehensive data about the patient's health status. This step is crucial in identifying problems and setting priorities for care. Choice B comes in the second phase (diagnosis), C in the third phase (planning), and D in the last phase (evaluation). Assessing the patient's condition is the foundation for the rest of the nursing process.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. In the first phase of the nursing process (assessment), the nurse collects data to form a comprehensive database about the patient's health status. This step is crucial as it provides the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining whether outcomes have been achieved (D) is in the fourth phase (evaluation). Completing a comprehensive database in the first phase ensures a thorough understanding of the patient's needs before proceeding to the next steps in the nursing process.
A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)
- A. Order chest x-ray for suspected arm fracture.
- B. Prescribe antibiotics for a wound infection.
- C. Reposition a patient who is on bed rest.
- D. Teach a patient preoperative exercises.
Correct Answer: C
Rationale: Step 1: Repositioning a patient who is on bed rest is a nursing intervention as it involves direct patient care to prevent complications like pressure ulcers.
Step 2: Nursing interventions aim to promote patient health, prevent illness, and provide comfort.
Step 3: Ordering chest x-ray and prescribing antibiotics are medical interventions, beyond the scope of nursing practice.
Step 4: Teaching preoperative exercises falls under nursing education but not a direct nursing intervention involving patient care.
Summary: Choice C is correct as it aligns with the essence of nursing interventions focusing on patient care and wellbeing. Choices A, B, and D involve actions that are not within the scope of nursing interventions.
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.
Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- A. Flashing lights
- B. Lens opacity
- C. Halos around lights A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET N
Correct Answer: C
Rationale: The correct answer is C: Halos around lights. This symptom is specific to acute angle-closure glaucoma due to increased intraocular pressure causing corneal edema. Halos around lights are caused by light diffraction through edematous cornea. Flashing lights and lens opacity are not typically associated with acute angle-closure glaucoma. Flashing lights may be seen in retinal detachment, while lens opacity is more commonly seen in cataracts.