Nokea
A nurse is teaching a patient with asthma about proper inhaler use. Which of the following statements by the patient indicates the need for further education?
- A. I should hold my breath for 10 seconds after inhaling the medication.
- B. I should use my inhaler before exercise to prevent symptoms.
- C. I can use my inhaler every 30 minutes if I have trouble breathing.
- D. I should rinse my mouth after using my inhaler to prevent thrush.
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every 30 minutes for trouble breathing is not recommended. Overuse can lead to medication side effects and potential worsening of symptoms.
A: Holding breath after inhaling helps medication reach lungs.
B: Using inhaler before exercise can prevent exercise-induced symptoms.
D: Rinsing mouth prevents thrush, a common side effect of inhaled corticosteroids.
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An Aboriginal woman who lives away from the reserve has come to the clinic to seek help with regulating her diabetes. In conducting an interview, the nurse's priority involves:
- A. finding out why the patient is not compliant.
- B. reinforcing the health teaching related to diet and exercise.
- C. determining if the patient can afford her medications.
- D. sending the patient to the diabetic clinic for follow-up.
Correct Answer: C
Rationale: The correct answer is C because determining if the patient can afford her medications is crucial in managing her diabetes effectively. Financial constraints can significantly impact a patient's ability to adhere to treatment, leading to poor health outcomes. By addressing affordability, the nurse can ensure the patient can access and comply with the prescribed medications.
A, finding out why the patient is not compliant, is not the priority at this stage as addressing affordability comes first. B, reinforcing health teaching related to diet and exercise, is important but secondary to ensuring access to medications. D, sending the patient to the diabetic clinic for follow-up, is not as critical as addressing immediate financial concerns.
A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?
- A. Ask the patient to take deep breaths
- B. Have the patient sit upright
- C. Examine for symmetry
- D. Ask the patient to lie flat and breathe normally
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients.
A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately.
B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds.
C: Examining for symmetry is important but not directly related to the optimal position for auscultation.
A nurse is providing education to a patient with chronic liver disease. The nurse should educate the patient to monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Hyperglycemia.
- C. Jaundice.
- D. Anemia.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Patients with chronic liver disease are at risk for developing jaundice due to impaired liver function leading to the accumulation of bilirubin. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates worsening liver function.
Incorrect choices:
A: Hypoglycemia - Not directly related to chronic liver disease, more commonly seen in diabetes.
B: Hyperglycemia - Not typically associated with chronic liver disease unless the patient has underlying diabetes.
D: Anemia - Can be a complication of chronic liver disease, but monitoring for jaundice takes priority due to its direct association with liver dysfunction.
A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?
- A. Increasing sodium intake.
- B. Losing weight and increasing physical activity.
- C. Consuming more processed foods.
- D. Limiting fluid intake.
Correct Answer: B
Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels.
A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure.
C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure.
D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.
Which of the following questions would best assess a person's judgement?
- A. Do you feel that you are being watched, followed, or controlled?
- B. Tell me about what you plan to do once you are discharged from the hospital.
- C. What does the saying, "People in glass houses shouldn't throw stones' mean to you?
- D. What would you do if you found a stamped, addressed envelope on the sidewalk?
Correct Answer: B
Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.