Nokea
A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.
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A 32-year-old female patient complains that she has noticed several small, slightly raised, bright-red dots on her chest. On examination, the nurse thinks that the spots are probably:
- A. Anasarca.
- B. Scleroderma.
- C. Senile angiomas.
- D. Latent myeloma.
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign growths of small blood vessels that appear as bright-red dots on the skin, commonly seen in older individuals. In this case, the patient is 32 years old, which is relatively young for an appearance of senile angiomas, but still within the possible age range. Anasarca (A) is generalized edema, not related to the described skin condition. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not associated with bright-red dots. Latent myeloma (D) is a type of bone marrow cancer and not related to the skin findings described.
A nurse is providing discharge instructions to a patient who had a stroke. Which of the following statements by the patient indicates the need for further education?
- A. I will take my medications as prescribed.
- B. I will follow up with my doctor regularly.
- C. I can resume driving after a few weeks of rest.
- D. I will report any sudden changes in my vision or speech.
Correct Answer: C
Rationale: The correct answer is C. After a stroke, patients need to be evaluated by a healthcare professional before resuming driving. This is crucial to ensure the safety of the patient and others on the road. Choice A shows medication compliance, B demonstrates follow-up care, and D emphasizes monitoring symptoms, all of which are essential post-stroke. However, choice C indicates a lack of understanding about the importance of medical clearance before driving, hence the need for further education.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Deep vein thrombosis (DVT).
- C. Wound infection.
- D. Hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.
Which of the following statements about mental health assessment is true?
- A. The mental health assessment diagnoses specific psychiatric disorders.
- B. Mental disorders occur in response to everyday life stressors.
- C. Mental status is inferred through assessment of an individual's behaviours.
- D. Mental health can be assessed directly, just like the characteristics of any other body system (e.g., cardiac and breath sounds).
Correct Answer: C
Rationale: The correct answer is C because mental status is indeed inferred through assessment of an individual's behaviors. Mental health assessment involves observing and evaluating a person's thoughts, emotions, behaviors, and overall mental functioning to determine their mental status. This includes assessing speech, mood, cognition, and perception. Choices A, B, and D are incorrect because:
A: Mental health assessment does not solely focus on diagnosing specific psychiatric disorders; it is a broader evaluation of an individual's mental well-being.
B: Mental disorders can result from a variety of factors beyond everyday life stressors, such as genetic predisposition or traumatic experiences.
D: Mental health assessment is more complex than assessing physical characteristics and involves subjective interpretation of behaviors rather than direct observation like physical assessments.
Which technique should be used to assess a murmur in a patient's heart?
- A. The bell of the stethoscope
- B. The diaphragm of the stethoscope
- C. Palpation with the palm of the hand
- D. Ask another nurse to double-check the finding.
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location.
A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs.
C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs.
D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.