Nokea
A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?
- A. Perform the task for the patient
- B. Tell the patient not to worry about it
- C. Break the task down into simple steps
- D. Have another patient demonstrate how to perform the task
Correct Answer: C
Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion.
Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.
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Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?
- A. “Why didn’t you go to the doctor when you began to have this pain?”
- B. “Are you feeling better now than you did during the night?”
- C. “Tell me more about what caused your pain.”
- D. “If I were you, I would not wait to get medical help next time.”
Correct Answer: C
Rationale: The correct answer is C because it encourages the patient to provide more detailed information about the cause of their pain, which can help in understanding the underlying health issues. Choice A is judgmental and may make the patient defensive. Choice B is closed-ended and does not prompt for specific details. Choice D is directive and may not be well-received by the patient. Asking the patient to elaborate on what caused their pain allows for a more open-ended response, leading to a more thorough health history assessment.
Which of the ff signs may be revealed by a visual examination in a client with tonsillar infection if group A streptococci is the cause?
- A. White patches on the tonsils
- B. Hypertrophied tonsils
- C. Hemorrhage in the tonsils
- D. Bleeding in the tonsils
Correct Answer: A
Rationale: The correct answer is A: White patches on the tonsils. Group A streptococci infection commonly presents with exudative tonsillitis, characterized by the presence of white patches or pus on the tonsils. This is due to the inflammatory response triggered by the bacteria. Hypertrophied tonsils (B), hemorrhage in the tonsils (C), and bleeding in the tonsils (D) are less likely to be visual signs of a streptococcal infection and are more indicative of other conditions or complications. Therefore, white patches on the tonsils are the most specific visual sign associated with group A streptococci tonsillar infection.
The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
- A. Assisting with activities of daily living
- B. Counseling about respite care options
- C. Teaching range-of-motion exercises
- D. Consulting with a social worker
Correct Answer: B
Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout.
A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain.
C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain.
D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.
Correct method of mouth to mouth respiration is that the victim’s chin is held:
- A. Forward
- B. Backward
- C. Sideward
- D. Downward
Correct Answer: D
Rationale: The correct answer is D (Downward) because it helps to maintain a clear airway for effective mouth-to-mouth respiration. By holding the victim's chin downward, you can ensure proper alignment of the airway, allowing the tongue to fall forward and prevent obstruction. Holding the chin forward (Choice A) may cause the airway to close, holding it backward (Choice B) may strain the neck, and holding it sideward (Choice C) may not provide optimal airway alignment. Holding the chin downward is the most effective and safe method for providing mouth-to-mouth respiration.
Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
- A. "I think you should ask the doctor. Would you like me to cail him for you?"
- B. " The blood supply to the brain has decreased causing permanent brain damage."
- C. "It Is a temporary interruption in the blood flow to the brain."
- D. "TIA means a transient ischemic attack."
Correct Answer: C
Rationale: The correct answer is C because it accurately defines a transient ischemic attack (TIA) as a temporary interruption in blood flow to the brain. This response demonstrates the nurse's knowledge and ability to provide accurate information to the family member.
Option A is incorrect because it deflects the question to the doctor without providing any information. Option B is incorrect because it inaccurately states that TIA causes permanent brain damage, which is not true. Option D is also incorrect because it simply restates the abbreviation without providing any explanation of what TIA actually means.