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A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:
- A. collect a follow-up database and then check the patient's blood pressure.
- B. ask the patient to read her health record and indicate any changes since her last visit.
- C. check only the blood pressure because the patient's complete health history was documented 2 months ago.
- D. obtain a complete health history before checking the blood pressure because much of the patient's information may have changed.
Correct Answer: A
Rationale: Rationale:
1. Collecting a follow-up database ensures up-to-date information.
2. It allows for monitoring of medication effectiveness and any new symptoms.
3. Checking the blood pressure is essential but needs current context.
4. Asking the patient to read her record may not provide all necessary updates.
5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.
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When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which of the following statements about this situation is true?
- A. The nurse should focus on the patient's verbal message and try to ignore the nonverbal behaviors.
- B. The nurse should ask someone who knows the patient well to help interpret this discrepancy.
- C. The nurse should try to integrate the verbal and nonverbal messages and then interpret them as an 'average.'
- D. The nurse should focus on the patient's nonverbal behaviors because these are often more reflective of a patient's true feelings.
Correct Answer: B
Rationale: The correct answer is B because asking someone who knows the patient well can provide valuable insight into the meaning behind the verbal and nonverbal communication discrepancy. This helps in understanding the context and potential reasons for the inconsistency. Option A is incorrect as ignoring nonverbal behaviors can lead to missing important cues. Option C of interpreting messages as an 'average' may oversimplify the complexity of communication. Option D is incorrect as while nonverbal behaviors can provide valuable information, solely focusing on them may not give a complete understanding of the situation.
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
- A. objective.
- B. reflective.
- C. subjective.
- D. introspective.
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
What is the priority nursing action for a client with a suspected stroke?
- A. Administer oxygen
- B. Administer aspirin
- C. Administer thrombolytics
- D. Place the client in a supine position
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.
What should be the nurse's first action for a client who has sustained a spinal cord injury?
- A. Immobilize the spine
- B. Assess the client's airway
- C. Place the client in a supine position
- D. Encourage deep breathing
Correct Answer: C
Rationale: The correct answer is C: Place the client in a supine position. This is the first action because it helps prevent further injury to the spinal cord by maintaining alignment. Immobilizing the spine (choice A) is important but should come after placing the client in a supine position. Assessing the client's airway (choice B) is crucial but not the first action in a spinal cord injury. Encouraging deep breathing (choice D) is not appropriate as the priority is to stabilize the spine. In summary, placing the client in a supine position is the initial step to prevent worsening of the spinal cord injury, while the other choices are important but secondary actions.
What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Monitor serum glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.