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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.
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A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of exacerbation?
- A. Increased sputum production and shortness of breath.
- B. Improved oxygen saturation.
- C. Increased energy levels.
- D. Decreased respiratory rate.
Correct Answer: A
Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications.
B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition.
C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations.
D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
- A. Peripheral vascular disease.
- B. Deep vein thrombosis.
- C. Cellulitis.
- D. Skin cancer.
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.
The nurse hears bilateral, louder, longer, and lower pitched tones when percussing over the lungs of a 4-year-old chilWhat should the nurse do next?
- A. Palpate over the area to identify increased pain and tenderness.
- B. Ask the child to take shallow breaths, and percuss over the area again.
- C. Refer the child immediately because of suspicion of an increased amount of air in the lungs.
- D. Consider this a normal finding for a child this age, and proceed with the examination.
Correct Answer: D
Rationale: The correct answer is D because in children, the lung sounds can be different due to their thinner chest walls and more prominent bronchial markings. The louder, longer, and lower-pitched tones heard upon percussion are normal findings in pediatric patients, indicating increased air content in the lungs. Palpating for pain or tenderness (choice A) is not necessary as these findings are expected in children. Asking the child to take shallow breaths and percussing again (choice B) is not needed as the initial findings are normal for the age group. Referring the child immediately (choice C) is unnecessary as these findings are within the normal range for a 4-year-old.
During an interview with a patient, at which distance would the nurse expect that most of the interview will take place?
- A. 1 m
- B. 1.5 m
- C. 2 m
- D. 3 m
Correct Answer: B
Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.
A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
- A. How do you usually feel? Is this normal behaviour for you?
- B. I am going to say four words. In a few minutes, I will ask you to recall them.
- C. Please describe the meaning of the phrase, "looking through rose-coloured glasses.'
- D. Please pick up the pencil in your left hand, move it to your right hand, and place it on the table.
Correct Answer: D
Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness.
Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.