Nokea
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.
You may also like to solve these questions
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
- A. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence
- B. A patient with reflex incontinence with elevated blood pressure and pulse rate
- C. A patient with an indwelling catheter that has stool on the catheter tubing
- D. A patient who has just voided and needs a postvoid residual test
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention.
Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B.
Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B.
Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?
- A. Position in semi-Fowler’s.
- B. Flex head with chin tuck.
- C. Place food on left side.
- D. Offer fruit juice.
Correct Answer: B
Rationale: The correct answer is B: Flex head with chin tuck. This position helps prevent aspiration by closing off the airway during swallowing. Flexing the head and tucking the chin promotes safe swallowing and reduces the risk of choking. Placing food on the left side (choice C) is not relevant to addressing the patient's symptoms. Positioning in semi-Fowler's (choice A) may not directly address the swallowing difficulty. Offering fruit juice (choice D) does not address the patient's specific feeding needs and may not be safe if the patient has swallowing difficulties.
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
- A. Risk for Infection Related to Skin Sloughing
- B. Risk for Acute Pain Related to Loss of Skin Integrity
- C. Risk for Impaired Skin Integrity Related to Cutaneous Lesions
- D. Risk for Impaired Gas Exchange Related to Airway Obstruction
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function.
A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange.
B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise.
C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.
A nurse is providing care to a patient from adifferent culture. Which action by the nurse indicates cultural competence?
- A. Communicates effectively in a multicultural context
- B. Functions effectively in a multicultural context
- C. Visits a foreign country
- D. Speaks a different language
Correct Answer: A
Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.
A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this patients psychosocial needs, what nursing action is most appropriate?
- A. Encourage the patient to focus on her use of her other senses.
- B. Assess and promote the patients coping skills during interactions with the patient.
- C. Emphasize that her lifestyle will be unchanged once she adapts to her vision loss.
- D. Promote the patients hope for recovery.
Correct Answer: B
Rationale: The correct answer is B because assessing and promoting the patient's coping skills is essential in addressing the psychosocial needs of a patient with macular degeneration. By understanding how the patient is coping with the vision loss, the nurse can tailor interventions to support the patient effectively. This approach acknowledges the patient's emotional responses and helps them navigate the challenges associated with the condition.
Choice A is incorrect as solely focusing on other senses may not address the psychological impact of vision loss. Choice C is incorrect as it dismisses the significant lifestyle changes the patient may experience. Choice D is incorrect as promoting hope for recovery may not be realistic in the case of irreversible conditions like macular degeneration.