Nokea
Bel1le has a difficulty tolerating frustration The GOAL Of the nurse is to assist Belle to ________.
- A. increase her self-esteem
- B. recognize her need
- C. cope with anxiety
- D. mobilize her resources
Correct Answer: C
Rationale: The correct answer is C: cope with anxiety. The nurse's goal is to address Belle's difficulty tolerating frustration, which likely leads to anxiety. By helping Belle develop coping strategies for managing her anxiety, the nurse can assist her in handling frustration more effectively. Options A, B, and D are incorrect because increasing self-esteem, recognizing needs, and mobilizing resources may be important aspects of Belle's overall care but are not directly related to addressing her difficulty with frustration and anxiety. Focusing on coping with anxiety directly targets the root issue and is the most appropriate goal in this context.
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A patient with a history of diabetes mellitus is admitted with a foot ulcer. Which nursing intervention is essential for preventing infection in the foot ulcer?
- A. Applying topical antibiotics
- B. Performing daily wound debridement
- C. Keeping the ulcer covered with a sterile dressing
- D. Administering oral antibiotics prophylactically
Correct Answer: C
Rationale: Rationale:
C is correct as keeping the ulcer covered with a sterile dressing provides a barrier against pathogens, promoting wound healing and preventing infection. A (topical antibiotics) can lead to resistance and disrupt normal flora. B (daily wound debridement) may introduce pathogens and delay healing. D (oral antibiotics prophylactically) is not recommended without evidence of infection.
A patient expresses distrust in the healthcare system due to previous negative experiences. What is the nurse's best approach to rebuild trust?
- A. Dismiss the patient's concerns and assure them that the healthcare team is trustworthy.
- B. Listen actively to the patient's concerns, acknowledge their past experiences, and work to rebuild trust through transparency and reliability.
- C. Ignore the patient's distrust and proceed with providing care.
- D. Tell the patient that their distrust is unfounded and they should trust the healthcare system.
Correct Answer: B
Rationale: The correct answer is B because actively listening, acknowledging the patient's concerns, and working towards rebuilding trust through transparency and reliability are essential steps in addressing distrust. By validating the patient's experiences and actively involving them in the process, the nurse can foster a supportive and trusting relationship.
Choice A is incorrect because dismissing the patient's concerns can further damage trust and undermine the patient's feelings. Choice C is incorrect as ignoring the distrust can lead to a breakdown in communication and trust. Choice D is incorrect because telling the patient to trust the healthcare system without addressing their concerns is dismissive and unhelpful.
A patient presents with severe headache, photophobia, and neck stiffness. On examination, there is nuchal rigidity and positive Kernig and Brudzinski signs. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Migraine headache
- B. Cluster headache
- C. Meningitis
- D. Subarachnoid hemorrhage
Correct Answer: C
Rationale: The correct answer is C: Meningitis. The patient's symptoms of severe headache, photophobia, neck stiffness, nuchal rigidity, and positive Kernig and Brudzinski signs are classic signs of meningitis. Meningitis is an inflammation of the meninges surrounding the brain and spinal cord, leading to these specific neurological symptoms. Migraine headache (A) typically presents with a throbbing headache, nausea, and sensitivity to light and sound, but does not typically cause neck stiffness or positive meningeal signs. Cluster headache (B) is characterized by severe unilateral headache with autonomic symptoms like tearing or nasal congestion, but does not typically cause neck stiffness or positive meningeal signs. Subarachnoid hemorrhage (D) presents with sudden severe headache often described as "the worst headache of my life," and may cause neck stiffness, but typically does not present with photophobia or positive meningeal signs like Kernig and Brudzinski signs.
Which of the following actions should be taken first when encountering a person experiencing an allergic reaction with signs of respiratory distress?
- A. Administer an epinephrine auto-injector.
- B. Position the person comfortably.
- C. Monitor vital signs.
- D. Assess the severity of the reaction.
Correct Answer: D
Rationale: The correct answer is D: Assess the severity of the reaction. This should be the first action taken because it helps determine the urgency of the situation and guides subsequent steps. Assessing the severity allows for appropriate intervention - from calling emergency services if the reaction is severe, to administering medication if necessary.
A: Administering an epinephrine auto-injector should only be done if the severity of the reaction warrants it, as it is a potent medication that can have serious side effects if used inappropriately.
B: Positioning the person comfortably is important, but assessing the severity of the reaction takes precedence to ensure prompt and appropriate care.
C: Monitoring vital signs is important, but assessing the severity of the reaction is crucial in determining the immediate course of action.
To promote drainage and reduce pressure from fluid, Nurse Selma nursing intervention is to have the child assume any of the following positions, EXCEPT _____.
- A. tilt head to side if sitting up.
- B. Lie on the affected area
- C. put the pillows behind the head
- D. lie on the non-affected ear.
Correct Answer: B
Rationale: The correct answer is B: Lie on the affected area. This position would hinder drainage and increase pressure on the affected area. A: Tilt head to the side if sitting up, is correct as it promotes drainage. C: Putting pillows behind the head can also aid drainage. D: Lying on the non-affected ear can help reduce pressure on the affected side.