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A patient has been in the critical care unit for 10 days. He has just been moved to the medical"“surgical unit, and the admitting nurse is planning to perform a mental health examination. During the cognitive function tests, the nurse would expect that he:
- A. Might display some disruption in thought content.
- B. Might state, "I am so relieved to be out of critical care.'
- C. Might be oriented to place and person but not be certain of the date.
- D. Might show evidence of some clouding of consciousness.
Correct Answer: C
Rationale: The correct answer is C. After being in critical care for 10 days, it is expected that the patient may be disoriented to time but still be oriented to place and person. This is a common occurrence due to the stressful and disorienting environment of the critical care unit. The patient's cognition may be temporarily affected, leading to difficulty in remembering the date accurately. The patient's ability to recognize their surroundings and identify themselves and others should still be intact. Choices A, B, and D are incorrect because disruption in thought content, expressing relief, and clouding of consciousness are not typical cognitive function issues expected in this scenario.
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A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train.' What is the best way for the nurse to communicate with this patient?
- A. Use speech because he will understand even if the nurse cannot understand him.
- B. Abandon all attempts to communicate with him. His aphasia is irreversible.
- C. Give him a pencil and paper because reading and writing abilities will not be impaired.
- D. Support his efforts to communicate, and use pantomime and gestures to communicate when possible.
Correct Answer: D
Rationale: The correct answer is D because the patient is showing signs of expressive aphasia, where they have difficulty with verbal expression. By supporting his efforts to communicate and using pantomime and gestures, the nurse can help bridge the communication gap and facilitate understanding. This approach acknowledges the patient's drive to communicate and helps him convey his thoughts effectively.
Option A is incorrect because although the patient may understand, the nurse needs to adapt the communication method to support the patient's expressive difficulties. Option B is incorrect as abandoning communication efforts would be detrimental to the patient's well-being and recovery. Option C is incorrect as the patient's ability to read and write may also be impaired due to the stroke, making this method less effective than using gestures and pantomime.
A nurse is teaching a patient with diabetes about managing their condition. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood glucose regularly.
- B. I can stop taking my insulin when my blood glucose is normal.
- C. I should only use my insulin when I feel symptoms of high blood sugar.
- D. I will eat sugary foods if I feel tired or weak.
Correct Answer: A
Rationale: The correct answer is A: "I will monitor my blood glucose regularly." This statement shows proper understanding as monitoring blood glucose levels is essential for managing diabetes effectively. Regular monitoring helps the patient track their blood sugar levels and make informed decisions about medication, diet, and lifestyle.
Incorrect choices:
B: Stopping insulin when blood glucose is normal can lead to dangerous complications.
C: Using insulin only when symptoms of high blood sugar are present is not a safe or effective approach.
D: Eating sugary foods when feeling tired or weak can cause blood sugar spikes and worsen diabetes control.
In summary, choice A is correct because it reflects the importance of consistent blood glucose monitoring in diabetes management, while the other choices suggest potentially harmful misconceptions.
A nurse is caring for a patient with chronic heart failure. Which of the following interventions should the nurse prioritize?
- A. Administering diuretics as prescribed.
- B. Encouraging increased fluid intake.
- C. Restricting sodium intake.
- D. Administering pain medications as needed.
Correct Answer: A
Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.
A nurse is caring for a patient who has undergone a total knee replacement. Which of the following interventions is most important to prevent post-operative complications?
- A. Encouraging early ambulation.
- B. Providing pain medication as needed.
- C. Monitoring for signs of infection.
- D. Administering antibiotics before surgery.
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. Early ambulation helps prevent complications such as deep vein thrombosis and pulmonary embolism by improving circulation and preventing blood clots. It also promotes joint mobility and muscle strength. Providing pain medication (B) is important but not as crucial as preventing complications. Monitoring for signs of infection (C) is essential but not the most important intervention. Administering antibiotics before surgery (D) does not directly prevent post-operative complications related to knee replacement.
Which of the following would be included in a total health database for a well person?
- A. Nursing goals for the patient
- B. Anticipated growth and development patterns
- C. A patient's perception of his or her health status
- D. The nurse's perception of disease as related to this patient
Correct Answer: C
Rationale: The correct answer is C: A patient's perception of his or her health status. In a total health database for a well person, it is important to include the patient's own perception of their health status as it provides valuable insights into their overall well-being and can help detect any potential health issues early on. This information is crucial for preventive care and promoting a patient-centered approach to healthcare.
A: Nursing goals for the patient - This information would be relevant for a patient with specific health goals or conditions but not necessarily for a well person.
B: Anticipated growth and development patterns - This information is more relevant for pediatric or adolescent populations rather than for a well adult.
D: The nurse's perception of disease as related to this patient - The nurse's perception is subjective and not as valuable as the patient's own perception in understanding their health status.