Nokea
As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
- A. I know the hallucinations are parts of the disease
- B. I told her she is wrong and I explained to her what is right
- C. I help her do some tasks he cannot do for himself
- D. Ill turn off the TV when we go to another room
Correct Answer: B
Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.
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An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.
The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
- A. increasing saturated fat intake and fasting in the afternoon.
- B. increasing intake of vitamins B and D and taking iron supplements.
- C. eating a candy bar if light-headedness occurs.
- D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D
Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
- A. Consider cultural differences during this assessment.
- B. Ask the patient to make eye contact to determine her affect.
- C. Continue with the interview and document that the patient is depressed.
- D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A
Rationale: Step 1: Recognize cultural differences in communication styles. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness.
Step 2: Understand that the patient's behavior may not indicate depression but rather a cultural norm.
Step 3: Adjust communication approach by respecting the patient's cultural preferences.
Step 4: Building trust and rapport by acknowledging and accommodating cultural differences.
Summary: Choice A is correct as it acknowledges and respects cultural differences. Choices B, C, and D are incorrect as they do not consider cultural aspects and may lead to misinterpretation and inappropriate actions.
Which of the ff. type of eyedrops does the nurse understand is given to constrict the pupil, permitting aqueous humor to flow around the lens?
- A. Osmotic
- B. Mydriatic
- C. Myotic
- D. Cycloplegic
Correct Answer: C
Rationale: The correct answer is C: Myotic. Myotic eyedrops constrict the pupil, allowing aqueous humor to flow around the lens. Myotic agents, such as pilocarpine, work by stimulating the sphincter muscle of the iris. Osmotic eyedrops (A) reduce intraocular pressure, mydriatic eyedrops (B) dilate the pupil, and cycloplegic eyedrops (D) paralyze the ciliary muscle to prevent accommodation.
The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.