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A patient often seems to have difficulty coming up with the right words. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up was so full that I decided to take the stairs.' The nurse will note on his chart that he is using or experiencing:
- A. Blocking.
- B. Neologism.
- C. Circumlocution.
- D. Circumstantiality.
Correct Answer: C
Rationale: The correct answer is C: Circumlocution. This patient is using circumlocution, which is a communication strategy where a person describes something in a roundabout way instead of using the specific word. In this case, the patient is describing an elevator as "the thing that you step into that goes up." This is a common feature of language difficulties seen in conditions like aphasia.
A: Blocking is when a person suddenly stops speaking in the middle of a sentence due to an inability to recall a word, which is not happening in this scenario.
B: Neologism is the creation of new words or phrases, which is not evident here.
D: Circumstantiality is a speech pattern where the person includes unnecessary details and goes off on tangents, which is not demonstrated in the patient's response.
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A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Administering antiemetics as needed.
- B. Encouraging early ambulation to prevent complications.
- C. Providing wound care and dressing changes.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery.
Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case.
Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications.
Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.
A nurse is teaching a patient with diabetes about blood glucose management. Which of the following statements by the patient indicates proper understanding?
- A. I should check my blood glucose levels regularly and adjust my insulin as needed.
- B. I can stop taking my insulin if my blood glucose is normal.
- C. I should skip meals if my blood sugar is high.
- D. I should only use my insulin when my blood sugar is over 200 mg/dL.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Regular blood glucose monitoring helps in understanding patterns and making informed decisions.
2. Adjusting insulin based on blood glucose levels is crucial for effective diabetes management.
3. This statement shows the patient's understanding of the need for personalized insulin adjustments.
4. It promotes self-management and proactive approach to blood sugar control.
Summary:
B: Stopping insulin abruptly can lead to dangerous complications.
C: Skipping meals can disrupt blood sugar levels and is not recommended.
D: Waiting for high blood sugar to use insulin can result in uncontrolled levels and complications.
A nurse is teaching a patient with asthma about managing an asthma attack. Which of the following statements by the patient indicates proper understanding?
- A. I will use my inhaler every time I feel an asthma attack coming on.
- B. I will wait for the symptoms to subside on their own before using my inhaler.
- C. I will use my inhaler even if I don't feel any symptoms.
- D. I will not use my inhaler if my symptoms are mild.
Correct Answer: A
Rationale: Rationale: Choice A is correct because using the inhaler at the onset of symptoms can help prevent the asthma attack from worsening. This early intervention can be crucial in managing asthma effectively. Waiting for symptoms to subside (Choice B) can be risky as it may delay necessary treatment. Using the inhaler preventively (Choice C) without symptoms is unnecessary and can lead to overuse. Not using the inhaler for mild symptoms (Choice D) can allow the condition to escalate. Thus, Choice A is the most appropriate response for managing an asthma attack effectively.
When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?
- A. Identifying existing levels of wellness
- B. Evaluating previous problems and goals
- C. Identifying potential problems the individual may develop
- D. Focusing on strengths and reflecting an individual's transition to higher levels of wellness
Correct Answer: C
Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.
A pregnant woman states, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?
- A. It was a nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman's fears.
- B. It was a therapeutic response. The nurse should have shared her own experience with the patient to make her feel better.
- C. It was a nontherapeutic response. The nurse is essentially giving the message to the woman that labour cannot be tolerated without medication.
- D. It was a therapeutic response. By providing false assurance, the nurse created a sense of security and opened the door for more discussion.
Correct Answer: B
Rationale: The correct answer is B because the nurse's response was therapeutic by sharing her own experience to empathize with the patient. This helps establish a connection and validate the patient's feelings. It shows understanding without dismissing the patient's concerns.
A is incorrect because the nurse did not provide false reassurance but offered a comforting perspective.
C is incorrect as the nurse did not imply that medication was necessary but rather highlighted its availability as an option.
D is incorrect since the response did not provide false assurance but rather shared personal experience to offer support.