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A nurse is taking a history on a patient whocannot speak English. Which action will the nurse take?
- A. Obtain an interpreter.
- B. Refer to a speech therapist.
- C. Let a close family member talk.
- D. Find a mental health nurse specialist.
Correct Answer: A
Rationale: The correct answer is A: Obtain an interpreter. This is the best action as it ensures effective communication and accurate understanding of the patient's history and needs. Using a professional interpreter maintains confidentiality, avoids misinterpretation, and promotes cultural sensitivity. Referring to a speech therapist (B) is not appropriate for language barriers. Letting a family member talk (C) may compromise privacy and accuracy. Finding a mental health nurse specialist (D) is not needed for language translation.
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The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond?
- A. Privately ask the son to allow the patient to make his own health care decisions.
- B. Explain to the patient that he is responsible for his own decisions.
- C. Work with the team to negotiate informed consent.
- D. Avoid divulging information to the eldest son.
Correct Answer: C
Rationale: The correct answer is C: Work with the team to negotiate informed consent. In this scenario, the nurse should prioritize respecting the patient's cultural beliefs while also ensuring the patient's autonomy and right to make decisions about his own healthcare. By working with the healthcare team to negotiate informed consent, the nurse can involve both the patient and his eldest son in the decision-making process, ensuring that the patient's preferences are respected while also upholding ethical principles of patient autonomy and beneficence. This approach promotes collaboration and respect for cultural values while still safeguarding the patient's rights.
Choice A is incorrect because it does not involve the patient in the decision-making process and could undermine his autonomy. Choice B is incorrect as it disregards the patient's cultural beliefs and preferences. Choice D is incorrect as it may violate the patient's right to information and involvement in his own care.
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
- A. Risk for infection
- B. Impaired spontaneous ventilation
- C. Unilateral neglect
- D. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. Patients with Parkinson's disease are at risk for falls due to symptoms like tremors and impaired balance. Educating the family about fall prevention measures is crucial. Choice A, Risk for infection, is not directly related to Parkinson's disease. Choice B, Impaired spontaneous ventilation, is not a common concern in Parkinson's disease. Choice C, Unilateral neglect, is more commonly seen in conditions like stroke, not Parkinson's disease. Therefore, the most appropriate nursing diagnosis for the patient with Parkinson's disease is addressing the risk for injury to prevent falls.
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
- A. Aggressively continuing to fight the disease process
- B. Moving the patient to a long-term care facility when it becomes necessary
- C. Including the children in planning their fathers care
- D. Supporting the patients and familys values and choices
Correct Answer: D
Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.
A nurse is caring for an immigrant with low income.Which information should the nurse consider when planning care for this patient?
- A. There is a decreased frequency of morbidity.
- B. There is an increased incidence of disease.
- C. There is an increased level of health.
- D. There is a decreased mortality rate.
Correct Answer: B
Rationale: The correct answer is B: There is an increased incidence of disease. Low-income immigrants often face barriers to healthcare access, leading to higher rates of undiagnosed and untreated health conditions. This information is crucial for the nurse to plan appropriate care interventions.
Incorrect choices:
A: Decreased frequency of morbidity is not accurate as low-income immigrants may experience higher rates of illness due to lack of resources.
C: Increased level of health is unlikely in this population due to socioeconomic factors affecting health outcomes.
D: Decreased mortality rate is not supported as low-income immigrants may have higher mortality rates due to limited access to healthcare.
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
- A. Perianal region and oral mucosa
- B. Sacral region and lower abdomen
- C. Scalp and skin over the scapulae
- D. Axillae and upper thorax
Correct Answer: A
Rationale: The correct answer is A: Perianal region and oral mucosa. In patients with AIDS, these areas are more prone to opportunistic infections due to decreased immune function. The perianal region can be affected by conditions like anal warts or herpes, while the oral mucosa can develop oral thrush or other oral infections. By prioritizing assessment of these areas, the nurse can promptly identify any potential issues and initiate appropriate interventions.
Choice B: Sacral region and lower abdomen are not typically high-risk areas for skin integrity issues in AIDS patients.
Choice C: Scalp and skin over the scapulae are not commonly affected by opportunistic infections related to AIDS.
Choice D: Axillae and upper thorax are not as commonly affected as the perianal region and oral mucosa in AIDS patients.