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A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient’s daughter runs out of the room and says, “My mother can’t talk. Somebody help!” Which response by the nurse is best?
- A. Explain to the daughter that this is not uncommon, esp. in the afternoon when the patient is tired from the morning care activities.
- B. Do a quick assessment to confirm the change in the patient’s status, then notify the RN or physician.
- C. Call the speech therapist to come and to do a comprehensive speech assessment.
- D. Show the daughter how to do the speech exercises with her mother that were provided by the therapist
Correct Answer: B
Rationale: The correct answer is B. The nurse should do a quick assessment to confirm the change in the patient's status, then notify the RN or physician. This is the best response because the nurse needs to immediately assess the patient's condition to ensure prompt intervention if needed. By confirming the change in the patient's status, the nurse can provide the necessary information to the healthcare team for appropriate evaluation and management. The other choices are incorrect because: A does not address the urgency of the situation, C involves unnecessary delay by waiting for the speech therapist, and D is not appropriate as the nurse should be the one assessing and notifying the healthcare team.
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A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
- A. Is written as a two-part statement
- B. Describes human response to a health problem
- C. Describes potential for enhancement to a higher state
- D. Made when not enough evidence supports the problem
Correct Answer: A
Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.
Monthly examination (BSE) can help in early detection of breast CA. When do you perform BSE?
- A. once a month after menstruation
- B. every ether month after menstruation
- C. once a month before menstruation
- D. every other month before menstruation
Correct Answer: A
Rationale: The correct answer is A: once a month after menstruation. Performing BSE at this time helps ensure consistent examination when breasts are less tender or swollen, making it easier to detect abnormalities. Performing it once a month ensures regular monitoring for any changes. Choices B, C, and D are incorrect because they do not provide the recommended frequency or timing for an effective BSE. BSE should be done monthly after menstruation to increase the chances of early detection of breast cancer.
A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?
- A. The client sees letters at 20 feet that others can read at 40 feet
- B. The client sees letters at 40 feet that others can read at 20 feet
- C. The client sees colors at 20 feet that others can see at 40 feet
- D. The client sees colors at 40 feet that others can see at 20 feet
Correct Answer: A
Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet.
Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue.
A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty.
B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition.
C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem.
In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange.
Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.