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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 question corresponds to the "P" in PQRST, which stands for Provocation/Palliation. By asking where the pain is located, the nurse is gathering information about what triggers or relieves the pain, aiding in the assessment of the chest pain. The other choices are incorrect because:
B: What causes the pain? - This question corresponds to the "Q" in PQRST, which stands for Quality. It focuses on understanding the characteristics of the pain, not the cause.
C: Does it come and go? - This question corresponds to the "R" in PQRST, which stands for Radiation. It pertains to whether the pain spreads to other areas, not if it comes and goes.
D: What does the pain feel like? - This question corresponds to the "S" in PQRST, which stands for Severity. It relates to the intensity of the pain, not its location.
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The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
- A. Has intercourse with just the spouse
- B. Makes a donation of a pint of whole blood
- C. Limits sexual contact to those without HIV antibodies
- D. Uses a'condom each time there is a sexual intercourse
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV.
2. It eliminates the risk of contracting HIV from multiple sexual partners.
3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV.
4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission.
Summary:
- Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV.
- Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
- A. Voiding of 350mL of concentrated urine in 8 hours
- B. Respiratory rate of 8breaths/min
- C. Irregular heart rate of 82 beats/min
- D. Pupils constricted and equal A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET J
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest.
A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding.
C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically.
D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, “I refuse to take care of that dirty old man!” Which response by the nurse is best?
- A. “The next time he tries to touch you inappropriately, lightly smack his hand and tell him no!”
- B. “His stroke has made him less inhibited. We’ll see if we can find a male assistant to help him.”
- C. “We have to take care of all patients equally, even the dirty old men.”
- D. “He didn’t mean anything by it, just ignore it.”
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the patient's behavior is likely due to the stroke affecting his inhibitions. Finding a male assistant respects both the patient's dignity and the nursing assistant's comfort. Choice A is inappropriate as physical violence is never an acceptable response. Choice C lacks empathy and understanding of the situation. Choice D minimizes the seriousness of the behavior and fails to address the issue. B is the best option for promoting a safe and respectful environment for both the patient and staff.
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
- A. No sputum or cough present in 4 days
- B. Congestion throughout all lung fields in 2 days
- C. Shallow, fast respirations 30 breaths per minute in 1 day
- D. Lungs clear to auscultation following use of inhaler
Correct Answer: D
Rationale: The correct evaluative measure is D: Lungs clear to auscultation following use of inhaler. This choice aligns with the expected outcome of having no secretions present in the lungs in 48 hours. By using an inhaler to clear the lungs, the nurse can assess if the expected outcome is being met. This measure directly evaluates the presence of secretions in the lungs, in line with the established goal.
Incorrect Choices:
A: No sputum or cough present in 4 days - This measure does not align with the expected outcome of having no secretions present in the lungs in 48 hours.
B: Congestion throughout all lung fields in 2 days - This indicates a worsening condition and does not demonstrate progress towards the goal.
C: Shallow, fast respirations 30 breaths per minute in 1 day - This measure is unrelated to the presence of secretions in the lungs and the goal of avoiding shortness of breath with activity.
As the nurse cares for a patient with angioedema, differs from urticaria in that angioedema is characterized by which of the following?
- A. Angioedema is more pruritic.
- B. Angioedema has small, fluid-filled vesicles
- C. Angioedema has a deeper and more that crust.
- D. Angioedema lasts a shorter time.
Correct Answer: C
Rationale: Step-by-step rationale for choice C: Angioedema differs from urticaria as it involves deeper swelling in the dermis and subcutaneous tissue, leading to a more profound and firm texture. This contrasts with urticaria, which presents as superficial, raised wheals on the skin. Therefore, option C is correct.
Summary of other choices:
A: Angioedema is not typically associated with intense itching, so it is not more pruritic than urticaria.
B: Angioedema does not have small, fluid-filled vesicles like in allergic contact dermatitis.
D: Angioedema tends to last longer than urticaria, making this statement incorrect.