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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.
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For Mrs. Allen's weight reduction program to be successful, what should the nurse explain?
- A. An anorexiant should be used 4-6 weeks at the beginning
- B. An intestinal bypass is recommended if rapid weight loss is not achieved
- C. Personal eating habits must be assessed objectively
- D. Complete fasting for a week is necessary
Correct Answer: C
Rationale: Assessing personal eating habits objectively helps identify areas for improvement and fosters sustainable lifestyle changes.
14. A patient newly diagnosed with type 2 diabetes has been given a prescription to start on an oral hypoglycemic. The patient tells the nurse she would rather control her blood sugar with herbal therapy. Which action should the nurse take?
- A. Advise the patient to discuss using herbal therapy with her physician.
- B. Advise the patient that herbal therapy is not safe and should not be used.
- C. Advise the patient to give the prescriptive medication time to work before using herbal therapy.
- D. Advise the patient that if she takes herbal therapy, she will have to monitor her blood sugar more often.
Correct Answer: A
Rationale: Referring the patient to her physician (option A) ensures that any decision regarding herbal therapy is made collaboratively and safely.
A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?
- A. Severe dyspnea
- B. Nausea
- C. Decreased level of consciousness
- D. Headache
Correct Answer: B
Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.
What does cromolyn sodium act to do?
- A. Combat respiratory infection
- B. Constrict smooth muscle in the bronchial tree
- C. Prevent the release of histamine
- D. Terminate an asthmatic attack
Correct Answer: C
Rationale: Cromolyn sodium inhibits mast cell degranulation, preventing histamine release.
Patients with rheumatoid arthritis typically have pain
- A. With activity.
- B. Only upon awakening.
- C. Late in the evening.
- D. All day without remission.
Correct Answer: A
Rationale: RA pain worsens with activity due to joint inflammation.