Nokea
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
- A. "It is a sharp, burning pain in my stomach."
- B. "I also have the sweats and nausea when I feel this pain."
- C. "I think this pain is telling me that something is wrong with me."
- D. "This pain happens every time I sit down to use the computer."
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
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A nurse is caring for a patient with a history of stroke. The nurse should prioritize which of the following interventions?
- A. Encouraging mobility to prevent pressure ulcers.
- B. Monitoring for signs of deep vein thrombosis (DVT).
- C. Administering antihypertensive medication.
- D. Providing psychological support.
Correct Answer: B
Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility.
Step 2: Monitoring for DVT signs is crucial for early detection and prevention.
Step 3: Prompt intervention can prevent life-threatening complications.
Step 4: Encouraging mobility (Choice A) is important but not the priority.
Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority.
Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.
Which condition is characterized by writhing, twisting movements of the face and limbs?
- A. epilepsy
- B. Parkinson's
- C. muscular sclerosis
- D. Huntington's chorea
Correct Answer: D
Rationale: The correct answer is D: Huntington's chorea. Huntington's chorea is a genetic disorder characterized by involuntary, writhing, and twisting movements of the face and limbs, known as chorea. This is due to degeneration of certain brain cells. Epilepsy (A) involves seizures, not specific movements. Parkinson's (B) is characterized by tremors and rigidity, not chorea. Multiple sclerosis (C) affects the central nervous system, causing a variety of symptoms, but not typically chorea.
What is the highest priority for a nurse treating a client with a stab wound to the chest?
- A. Secure the airway
- B. Administer oxygen
- C. Turn the mother
- D. Apply an abdominal binder
Correct Answer: A
Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.
What is the most important intervention for a client experiencing an allergic reaction?
- A. Administer epinephrine
- B. Administer antihistamines
- C. Administer corticosteroids
- D. Administer beta-blockers
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which of the following would be an appropriate response by the nurse?
- A. "How does your family react to your pain?"
- B. "That must be terrible. You probably pinched a nerve."
- C. "I've had back pain myself, and I know it can be excruciating."
- D. "How would you say the pain affects your ability to carry on your daily activities?"
Correct Answer: D
Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment.
Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.