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A nurse wants to find the daily weights of apatient. Which form will the nurse use?
- A. Database
- B. Progress notes
- C. Patient care summary
- D. Graphic record and flow sheet
Correct Answer: D
Rationale: The correct answer is D: Graphic record and flow sheet. The nurse will use a graphic record and flow sheet to document the patient's daily weights. This form allows for easy tracking and visualization of weight trends over time. Database (A) is used for storing large amounts of data but not ideal for daily weight tracking. Progress notes (B) are for narrative descriptions of patient care, not specific for daily weights. Patient care summary (C) provides an overview of the patient's care plan, not detailed daily weights.
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A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing?
- A. Resting energy expenditure (REE)
- B. Basal metabolic rate (BMR)
- C. Nutrient density
- D. Nutrients
Correct Answer: B
Rationale: The correct answer is B: Basal metabolic rate (BMR). BMR refers to the minimum amount of energy required to maintain basic physiological functions at rest. It accounts for about 60-75% of total energy expenditure. It is essential for sustaining life-sustaining activities such as breathing, circulating blood, and maintaining body temperature.
Incorrect Choices:
A: Resting energy expenditure (REE) is the total amount of energy expended by the body while at rest, including BMR and additional energy for daily activities.
C: Nutrient density refers to the amount of nutrients per calorie in a food item, not the energy needed at rest.
D: Nutrients are essential substances in food required for growth, maintenance, and repair, but they do not specifically refer to the energy needed at rest.
An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication?
- A. The patient who is oriented, pain free, and blind
- B. The patient who is alert, hungry, and has strong self-esteem
- C. The patient who is cooperative, depressed, and hard of hearing
- D. The patient who is dyspneic, anxious, and has a tracheostomy Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, tracheostomy, and anxiety all contribute to communication concerns. appropriate to facilitate communication?
Correct Answer: D
Rationale: The correct answer is D because a dyspneic patient with a tracheostomy may have difficulty speaking due to impaired airflow and mobility of the tongue. In this case, using alternative communication methods such as writing or using communication boards would be more effective.
Choice A is incorrect because being blind does not directly impact communication in this scenario. Choice B is incorrect as hunger, alertness, and self-esteem do not relate to the communication challenges presented. Choice C is incorrect as depression, while important to consider, is not the primary factor impacting communication in this case.
A patient has herpes simplex 2 viral infection (HSV2). The nurse recognizes that which of the following should be included in teaching the patient?
- A. The virus causes cold sores of the lips.
- B. The virus may be cured with antibiotics.
- C. The virus, when active, may not be contracted during intercourse.
- D. Treatment is aimed at relieving symptoms.
Correct Answer: D
Rationale: The correct answer is D because treatment for HSV2 focuses on relieving symptoms since the virus cannot be cured. Antiviral medications can help manage outbreaks and reduce the frequency and severity of symptoms. Option A is incorrect as HSV2 typically presents as genital herpes, not cold sores on the lips (usually caused by HSV1). Option B is incorrect since antibiotics are ineffective against viruses. Option C is incorrect as HSV2 is most contagious during active outbreaks, making it important to practice safe sex to prevent transmission.
A nurse is providing care to a patient from adifferent culture. Which action by the nurse indicates cultural competence?
- A. Communicates effectively in a multicultural context
- B. Functions effectively in a multicultural context
- C. Visits a foreign country
- D. Speaks a different language
Correct Answer: A
Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.
A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patients respiratory status. How should the nurse evaluate the patients respiratory status? Select all that apply.
- A. Facilitate lung function testing.
- B. Assess breath sounds.
- C. Measure the childs oxygen saturation by oximeter.
- D. Monitor the childs respiratory pattern. E) Assess the childs respiratory rate.
Correct Answer: B
Rationale: Rationale: Assessing breath sounds is crucial in evaluating respiratory status as it helps identify any signs of airway obstruction or respiratory distress. This includes listening for wheezing, crackles, or diminished breath sounds. Lung function testing (A) may not be feasible in an acute emergency situation. Oxygen saturation (C) is important but does not provide a comprehensive assessment of respiratory status. Monitoring respiratory pattern (D) and assessing respiratory rate (E) are important but do not directly assess breath sounds, which are vital in identifying immediate respiratory issues.