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During an interview, the nurse asks the patient to tell more about their shortness of breath. What is the verbal skill used?
- A. Reflection
- B. Facilitation
- C. Direct question
- D. Open-ended question
Correct Answer: D
Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.
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A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?
- A. Managing pain.
- B. Monitoring for infection.
- C. Preventing deep vein thrombosis (DVT).
- D. Ensuring proper positioning.
Correct Answer: C
Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.
A nurse is caring for a patient with chronic asthma. The nurse should monitor the patient for which of the following complications of asthma?
- A. Hypoglycemia.
- B. Oxygen toxicity.
- C. Hyperkalemia.
- D. Respiratory failure.
Correct Answer: D
Rationale: The correct answer is D: Respiratory failure. In chronic asthma, persistent inflammation and airway remodeling can lead to worsening lung function and respiratory distress, ultimately resulting in respiratory failure. Monitoring for signs of respiratory distress such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.
A: Hypoglycemia is not a typical complication of asthma.
B: Oxygen toxicity is not a common complication in asthma management unless high concentrations of supplemental oxygen are administered for prolonged periods.
C: Hyperkalemia is not directly associated with asthma but may occur as a complication of certain asthma treatments or comorbid conditions.
Therefore, the priority complication to monitor in a patient with chronic asthma is respiratory failure due to the progressive nature of the disease and the potential for acute exacerbations.
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
- A. nursing diagnosis.
- B. medical diagnosis.
- C. admission diagnosis.
- D. collaborative diagnosis.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs.
2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions.
3. It guides nurses in planning individualized care to meet patient's specific needs.
4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care.
5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission.
6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care.
Summary:
The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.
A nurse is caring for a patient who has undergone a knee replacement. The nurse should encourage which of the following to promote recovery?
- A. Strict bed rest for the first 48 hours.
- B. Ambulation as soon as possible after surgery.
- C. Limiting physical activity for 2 weeks post-op.
- D. Prolonged use of the affected leg in a cast.
Correct Answer: B
Rationale: The correct answer is B: Ambulation as soon as possible after surgery. Ambulation helps prevent complications like blood clots and aids in circulation and muscle strength. Bed rest can lead to stiffness and decrease in range of motion. Limiting physical activity delays recovery. Prolonged use of a cast can hinder mobility and delay rehabilitation.
The nurse is conducting a health interview with a patient named Salil. There is a language barrier, and no interpreter is available. Which of the following is the best example of an appropriate question for the nurse to ask in this situation?
- A. "Does Salil take medicine?"
- B. "Do you sterilize the bottles?"
- C. "Do you have nausea and vomiting?"
- D. "He has been taking his medicine, hasn't he?"
Correct Answer: A
Rationale: The correct answer is A: "Does Salil take medicine?" This is the best question because it is simple, direct, and focuses on gathering important medical information. It is clear and easy to understand even with a language barrier. Choice B is irrelevant and not related to the patient's health status. Choice C assumes symptoms without context. Choice D is inappropriate as it refers to the patient in the third person and includes a leading statement. Asking about medication directly is the most appropriate approach in this scenario.