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After listening to her, which statement would be included as part of a motivational interview?
- A. Why not?
- B. If you go to therapy, I’ll give you a back rub when you get back.
- C. I know you are tired but look how much easier walking was today than it was last week.
- D. Well, with that attitude, you will have trouble. The doctor ordered therapy because he thought it would help.
Correct Answer: C
Rationale: The correct answer is 'I know you are tired but look how much easier walking was today than it was last week.' This approach acknowledges the patient's feelings while highlighting progress, fostering motivation.
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You have just received the morning report from the night shift nurses. List the order of priority for assessing and caring for these patients.
- A. A patient who developed tumor lysis syndrome around 5:00 am.
- B. A patient with frequent reports of break-through pain over the past 24 hours.
- C. A patient scheduled for exploratory laparotomy this morning.
- D. A patient with anticipatory nausea and vomiting for the past 24 hours.
Correct Answer: A
Rationale: Tumor lysis syndrome is a life-threatening condition requiring immediate intervention, making it the top priority.
During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?
- A. Respiratory alkalosis
- B. Increased anteroposterior diameter of the chest
- C. Oxygen saturation level 96%
- D. Petechiae on chest
Correct Answer: B
Rationale: The correct answer is B: Increased anteroposterior diameter of the chest. In COPD and emphysema, the lungs lose their elasticity, causing the chest to become barrel-shaped with an increased anteroposterior diameter. This occurs due to hyperinflation of the lungs. This finding is known as "barrel chest" and is a classic sign of advanced COPD.
A: Respiratory alkalosis is not typically associated with COPD and emphysema.
C: An oxygen saturation level of 96% is within the normal range and does not specifically relate to the assessment findings in COPD and emphysema.
D: Petechiae on the chest are not typically associated with COPD and emphysema; they may be indicative of other conditions such as bleeding disorders.
An 88-year-old woman is brought to the health clinic for the first time by her 64-year-old daughter. During the initial comprehensive nursing assessment of the patient, what should the nurse do?
- A. Ask the daughter whether the patient has any urgent needs or problems.
- B. Interview the patient and daughter together so that pertinent information can be confirmed.
- C. Obtain a health history using a functional health pattern and assess activities of daily living (ADLs) and mental status.
- D. Refer the patient for an interdisciplinary comprehensive geriatric assessment because at her age she will have multiple needs.
Correct Answer: C
Rationale: Assessing ADLs, mental status, and obtaining a thorough health history ensures comprehensive understanding of the patient's needs.
When the nurse prepares to administer a preoperative medication to a patient, the patient tells the nurse that she really does not understand what the surgeon plans to do. What action should be taken by the nurse? What criterion of informed consent has not been met in this situation?
- A. Inform the surgeon immediately.
- B. Document the patient's statement.
- C. Administer the medication as ordered.
- D. Delay medication until the surgeon clarifies.
Correct Answer: A
Rationale: Informed consent requires that the patient understands the procedure, which hasn't been met here.
What are the criteria for diagnosing systemic inflammatory response syndrome (SIRS)?
- A. Dehydration
- B. Overhydration
- C. Electrolyte imbalance
- D. Hypertension
Correct Answer: A
Rationale: Dehydration results from fluid loss exceeding intake, causing symptoms like dry mucous membranes, poor skin turgor, and hypotension.