Nokea
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?
- A. “Do you have a family history of chest problems?”
- B. “Why don’t you use a laxative every night?”
- C. “Do you take anything to help your constipation?”
- D. “Everyone who ages has bowel problems.”
Correct Answer: C
Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes.
Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.
You may also like to solve these questions
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.
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
- A. Anxiety related to barium enema
- B. Impaired gas exchange related to asthma
- C. Impaired physical mobility related to incisional pain
- D. Nausea related to adverse effect of cancer medication
Correct Answer: A
Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs.
Summary:
B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition.
C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself.
D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
- A. breath sounds
- B. blood pressure
- C. capillary refill
- D. butterfly rash
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct:
1. Blood pressure is vital in this scenario due to prednisone discontinuation.
2. Abruptly stopping prednisone can lead to adrenal insufficiency.
3. Adrenal insufficiency can cause hypotension, a life-threatening condition.
4. Monitoring blood pressure can help detect and manage potential complications.
Summary of other choices:
A: Breath sounds – Important but not the priority in this specific situation.
C: Capillary refill – Useful for assessing circulation but not urgent in this context.
D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
- A. Hand bell and extra bed linen
- B. Footboard and splint
- C. Sandbag and trochanter rolls
- D. Suction machine and gloves
Correct Answer: B
Rationale: Step-by-step rationale for choice B: Footboard and splint:
1. Footboard helps prevent foot drop by maintaining proper alignment and preventing pressure ulcers.
2. Splint helps stabilize and support Franco's limbs to prevent contractures and maintain proper positioning.
3. Both items are essential for Franco's safety, comfort, and prevention of complications.
4. Hand bell and extra bed linen (Choice A) are not crucial for Franco's immediate care needs.
5. Sandbag and trochanter rolls (Choice C) are not directly relevant to Franco's specific conditions.
6. Suction machine and gloves (Choice D) are important for airway management but not the priority for bedside equipment in this case.
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.