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A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.
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The neurologist tests the 4th and 6th cranial nerves together by having a patient do which of the following?
- A. Turn his head to the right and left
- B. Say “ahhh”
- C. Identify whispering in his ears
- D. Follow his finger with his eyes
Correct Answer: D
Rationale: The correct answer is D because testing the 4th (trochlear) and 6th (abducens) cranial nerves involves assessing eye movements. The trochlear nerve controls downward and inward eye movement, while the abducens nerve controls lateral eye movement. Asking the patient to follow the finger with their eyes tests the function of both nerves simultaneously. Choices A, B, and C do not specifically target the 4th and 6th cranial nerves, making them incorrect options.
A mother brings her children into the clinic and they are diagnosed with chickenpox. The mother had chickenpox as a child and is not concerned with contracting the disease when caring for her children. what type of immunity does this mother have?
- A. Active natural immunity
- B. Passive artificial immunity
- C. Passive natural immunity
- D. Active artificial immunity
Correct Answer: A
Rationale: The correct answer is A: Active natural immunity. The mother had chickenpox as a child, which triggered her immune system to produce antibodies, providing long-lasting protection. This is an example of active immunity because her immune system actively responded to the pathogen.
Summary:
B: Passive artificial immunity - This involves receiving pre-made antibodies, not produced by the individual's immune system.
C: Passive natural immunity - This is acquired through placental transfer or breastfeeding, not through prior exposure to the pathogen.
D: Active artificial immunity - This is acquired through vaccination, not through natural exposure to the pathogen.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect as it assumes the patient's fear is related to dressing changes, not discharge. Choice B is incorrect as resuming medications is not linked to the patient's fear of being alone. Choice D is incorrect as there is no indication in the scenario that the surgery was unsuccessful.
When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
- A. Wear gloves at all times
- B. Wear gown and mask at all times
- C. Wear gloves for blood/body fluid contact
- D. Wear a mask during patient contact times
Correct Answer: C
Rationale: The correct answer is C: Wear gloves for blood/body fluid contact. This is the most appropriate action for infection control when caring for a patient with AIDS because HIV is primarily transmitted through blood and certain body fluids. Wearing gloves when coming into contact with blood or body fluids reduces the risk of transmission.
Explanation for why other choices are incorrect:
A: Wearing gloves at all times may not be necessary and can lead to unnecessary waste of resources.
B: Wearing gown and mask at all times is excessive and not indicated unless there is a risk of exposure to blood or body fluids.
D: Wearing a mask during patient contact times is not necessary unless there is a risk of exposure to respiratory secretions.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C: The patient is apprehensive about discharge. This is the correct answer because the patient's fear of going home and being alone indicates apprehension about discharge, which is a common feeling among patients transitioning from the hospital to home care. This subjective data suggests that the patient may need additional support and education prior to discharge to address their fears and concerns.
A: The patient can now perform the dressing changes without help - This is incorrect because the patient's fear of going home and being alone does not necessarily indicate their ability to perform dressing changes independently.
B: The patient can begin retaking all of the previous medications - This is incorrect as the fear expressed by the patient is related to being alone at home, not to medication management.
D: The patient’s surgery was not successful - This is incorrect as there is no indication in the subjective data provided that the surgery was not successful.