Nokea
A woman is describing the problems she is having with her 2-year-old son. "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." The nurse's best verbal response would be:
- A. Go on, I'm listening.
- B. Fits? Tell me what you mean by this.
- C. Yes, it can be upsetting when a child has a fit.
- D. Don't be upset when he has a fit; every 2-year-old has fits.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively.
Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.
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When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which of the following statements about this situation is true?
- A. The nurse should focus on the patient's verbal message and try to ignore the nonverbal behaviors.
- B. The nurse should ask someone who knows the patient well to help interpret this discrepancy.
- C. The nurse should try to integrate the verbal and nonverbal messages and then interpret them as an 'average.'
- D. The nurse should focus on the patient's nonverbal behaviors because these are often more reflective of a patient's true feelings.
Correct Answer: B
Rationale: The correct answer is B because asking someone who knows the patient well can provide valuable insight into the meaning behind the verbal and nonverbal communication discrepancy. This helps in understanding the context and potential reasons for the inconsistency. Option A is incorrect as ignoring nonverbal behaviors can lead to missing important cues. Option C of interpreting messages as an 'average' may oversimplify the complexity of communication. Option D is incorrect as while nonverbal behaviors can provide valuable information, solely focusing on them may not give a complete understanding of the situation.
What instructions should the nurse give to a client undergoing mammography?
- A. Be sure to use underarm deodorant
- B. Do not use underarm deodorant
- C. Do not eat or drink after midnight
- D. Have a friend drive you home
Correct Answer: B
Rationale: The correct answer is B: Do not use underarm deodorant. This is important because deodorant can interfere with the mammogram results, leading to false readings. It is crucial to have a clean and uncontaminated image for an accurate diagnosis. Choice A is incorrect as it can affect the quality of the mammogram. Choices C and D are irrelevant to the mammography procedure and not necessary instructions for the client.
A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following lab results would the nurse expect to be elevated in this patient?
- A. Blood urea nitrogen (BUN).
- B. Calcium.
- C. Potassium.
- D. Sodium.
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
- A. Breathing, pain, sleep
- B. Breathing, sleep, pain
- C. Sleep, breathing, pain
- D. Sleep, pain, breathing
Correct Answer: A
Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first.
Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.
What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Monitor serum glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.