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A patient with diabetes is experiencing a hypoglycemic episode. Which of the following is the nurse's first priority in this situation?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Checking the patient's blood glucose level.
- D. Contacting the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.
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Which of the following is the appropriate health promotion question to ask during a review of symptoms?
- A. "Do you use sunscreen while outside?"
- B. "I need to see if your skin is warm and dry."
- C. "Have you experienced any dizziness or headaches?"
- D. "When you cough, what colour is the sputum you bring up?"
Correct Answer: A
Rationale: The correct answer is A: "Do you use sunscreen while outside?" because it directly relates to health promotion by addressing preventive measures. Sunscreen helps prevent skin cancer and other skin conditions. Choice B is incorrect as it focuses on assessing skin condition rather than promoting health. Choice C is incorrect as it relates to symptoms rather than prevention. Choice D is incorrect as it is related to assessing a specific symptom rather than promoting overall health.
Which of the following statements about mental health assessment is true?
- A. The mental health assessment diagnoses specific psychiatric disorders.
- B. Mental disorders occur in response to everyday life stressors.
- C. Mental status is inferred through assessment of an individual's behaviours.
- D. Mental health can be assessed directly, just like the characteristics of any other body system (e.g., cardiac and breath sounds).
Correct Answer: C
Rationale: The correct answer is C because mental status is indeed inferred through assessment of an individual's behaviors. Mental health assessment involves observing and evaluating a person's thoughts, emotions, behaviors, and overall mental functioning to determine their mental status. This includes assessing speech, mood, cognition, and perception. Choices A, B, and D are incorrect because:
A: Mental health assessment does not solely focus on diagnosing specific psychiatric disorders; it is a broader evaluation of an individual's mental well-being.
B: Mental disorders can result from a variety of factors beyond everyday life stressors, such as genetic predisposition or traumatic experiences.
D: Mental health assessment is more complex than assessing physical characteristics and involves subjective interpretation of behaviors rather than direct observation like physical assessments.
A patient tells the nurse that he is allergic to penicillin. Which of the following would be the nurse's best response to this information?
- A. "Are you allergic to any other drugs?"
- B. "How often have you received penicillin?"
- C. "I'll record your allergy information on your chart, so you won't receive any."
- D. "Please describe what happens to you when you take penicillin."
Correct Answer: D
Rationale: The correct answer is D: "Please describe what happens to you when you take penicillin." This response allows the nurse to gather detailed information about the patient's allergic reaction to penicillin, which is crucial for assessing the severity of the allergy and determining appropriate treatment options. By understanding the specific symptoms experienced by the patient, the nurse can help prevent potential adverse reactions in the future.
Choices A, B, and C are incorrect because:
A: This question does not address the immediate concern of the patient's penicillin allergy and does not help in understanding the nature of the allergic reaction.
B: The frequency of penicillin usage is not as relevant as understanding the nature and severity of the allergic reaction.
C: While recording allergy information is important, it does not address the need for understanding the patient's specific allergic response to penicillin.
A 60-year-old woman is undergoing a mammogram. The nurse explains that the procedure is done to:
- A. Detect any abnormal growths or tumors in the breast tissue.
- B. Identify changes in hormone levels.
- C. Evaluate lung function related to breast cancer.
- D. Assess for signs of osteoporosis.
Correct Answer: A
Rationale: The correct answer is A because mammograms are specifically designed to detect abnormal growths or tumors in the breast tissue, particularly in the early stages of breast cancer. This is crucial for early detection and effective treatment.
Choice B is incorrect because mammograms are not used to identify changes in hormone levels. Choice C is incorrect because mammograms do not evaluate lung function related to breast cancer. Choice D is incorrect because mammograms do not assess for signs of osteoporosis; a bone density scan is typically used for that purpose.
A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be:
- A. Lethargic.
- B. Obtunded.
- C. Stuporous.
- D. Semialert.
Correct Answer: A
Rationale: The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic.
Explanation for other choices:
B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse.
C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness.
D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.