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After providing care, a nurse charts in the patient’srecord. Which entry will the nurse document?
- A. Appears restless when sitting in the chair
- B. Drank adequate amounts of water
- C. Apparently is asleep with eyes closed
- D. Skin pale and cool
Correct Answer: D
Rationale: The correct answer is D because documenting the skin condition is an objective assessment that provides vital information about the patient's health status. Pale and cool skin may indicate poor perfusion or circulation issues. This observation is crucial for monitoring the patient's condition and identifying any potential concerns. Choices A, B, and C are subjective and do not provide specific or relevant information related to the patient's overall health status or response to care. Without objective data like skin appearance, it would be challenging to assess the patient's condition accurately.
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The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient which teaching points? (Select all that apply.)
- A. Increase physical activity.
- B. Keep total fat intake to 10% or less.
- C. Maintain body weight in a healthy range.
- D. Choose and prepare foods with little salt.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Increasing physical activity helps in maintaining a healthy weight and overall health.
2. Regular exercise can reduce the risk of chronic diseases like heart disease and diabetes.
3. Physical activity improves mental health and overall well-being.
4. Exercise boosts immunity and helps in managing stress levels.
Summary of why other choices are incorrect:
B. Keeping total fat intake to 10% or less is a specific dietary recommendation and not a comprehensive approach to staying healthy.
C. Maintaining body weight in a healthy range is important but does not encompass all aspects of staying healthy.
D. Choosing and preparing foods with little salt is a specific dietary recommendation and does not address the importance of physical activity in staying healthy.
An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting?
- A. The patient and family should be viewed as a single unit of care.
- B. Persistent symptoms of terminal illness should not be treated.
- C. Each member of the interdisciplinary team should develop an individual plan of care.
- D. Terminally ill patients should die in the hospital whenever possible.
Correct Answer: A
Rationale: The correct answer is A: The patient and family should be viewed as a single unit of care. In hospice care, the focus is on providing holistic care not only to the patient but also to their family members. This approach recognizes that the patient's well-being is interconnected with that of their loved ones. By viewing the patient and family as a single unit of care, hospice providers can address not just the physical symptoms but also the emotional, social, and spiritual needs of both the patient and their family. This principle emphasizes the importance of supporting the patient and their family through the end-of-life journey.
Summary:
- Choice B is incorrect as hospice care aims to manage symptoms effectively to improve quality of life.
- Choice C is incorrect as hospice care typically involves a collaborative interdisciplinary team working towards common goals.
- Choice D is incorrect as hospice care often prioritizes providing end-of-life care in a comfortable setting preferred by the patient.
An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication?
- A. The patient who is oriented, pain free, and blind
- B. The patient who is alert, hungry, and has strong self-esteem
- C. The patient who is cooperative, depressed, and hard of hearing
- D. The patient who is dyspneic, anxious, and has a tracheostomy Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, tracheostomy, and anxiety all contribute to communication concerns. appropriate to facilitate communication?
Correct Answer: D
Rationale: The correct answer is D because a dyspneic patient with a tracheostomy may have difficulty speaking due to impaired airflow and mobility of the tongue. In this case, using alternative communication methods such as writing or using communication boards would be more effective.
Choice A is incorrect because being blind does not directly impact communication in this scenario. Choice B is incorrect as hunger, alertness, and self-esteem do not relate to the communication challenges presented. Choice C is incorrect as depression, while important to consider, is not the primary factor impacting communication in this case.
A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect?
- A. Prolactinoma
- B. Angioma
- C. Glioma
- D. Adrenocorticotropic hormone (ACTH)producing adenoma
Correct Answer: A
Rationale: The correct answer is A: Prolactinoma. Hypogonadism is often associated with decreased testosterone levels, which can be caused by excessive prolactin secretion from a prolactinoma. Prolactin inhibits the secretion of gonadotropin-releasing hormone (GnRH), leading to decreased production of testosterone. Angioma, glioma, and ACTH-producing adenoma are not typically associated with hypogonadism. Angiomas are benign tumors of blood vessels, gliomas are tumors of the brain or spinal cord, and ACTH-producing adenomas are associated with Cushing's disease, not hypogonadism.
A nurse wants to find the daily weights of apatient. Which form will the nurse use?
- A. Database
- B. Progress notes
- C. Patient care summary
- D. Graphic record and flow sheet
Correct Answer: D
Rationale: The correct answer is D: Graphic record and flow sheet. The nurse will use a graphic record and flow sheet to document the patient's daily weights. This form allows for easy tracking and visualization of weight trends over time. Database (A) is used for storing large amounts of data but not ideal for daily weight tracking. Progress notes (B) are for narrative descriptions of patient care, not specific for daily weights. Patient care summary (C) provides an overview of the patient's care plan, not detailed daily weights.