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During the health assessment, the nurse notes that a patient is anxious and worried about upcoming surgery. What is the nurse's first priority in this situation?
- A. Assess the patient's emotional state and provide reassurance.
- B. Discuss the risks and benefits of the surgery in detail.
- C. Encourage the patient to relax and not focus on the surgery.
- D. Call the surgeon to inform them of the patient's anxiety.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's emotional state and provide reassurance. The first priority is to address the patient's anxiety and worry, as this can impact their overall well-being and ability to cope with the upcoming surgery. By assessing the emotional state, the nurse can understand the patient's concerns and provide appropriate support and reassurance. Discussing the risks and benefits (choice B) may be important but not the immediate priority. Encouraging relaxation (choice C) may not address the underlying anxiety. Calling the surgeon (choice D) is not necessary at this point as the nurse should first focus on the patient's emotional needs.
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A First Nations woman has come to the clinic for diabetes follow-up teaching. During the interview, the nurse notices that the patient never makes eye contact and speaks mostly looking down at the floor. Which of the following statements about this situation is true?
- A. She is nervous and embarrassed.
- B. She has something to hide and is ashamed.
- C. She is showing inconsistent verbal and nonverbal behaviours.
- D. She is showing that she is listening carefully to what the nurse is saying.
Correct Answer: D
Rationale: The correct answer is D because the patient's behavior of not making eye contact and looking down can be a sign of active listening and respect in some cultures, including many First Nations cultures. This behavior may indicate that the patient is focusing on what the nurse is saying and showing attentiveness. Making eye contact may be considered disrespectful or challenging in some cultures, so the lack of eye contact does not necessarily mean the patient has something to hide, is ashamed, or is nervous. Choice A assumes the patient is nervous or embarrassed without evidence. Choice B is an assumption without any basis, and choice C does not consider cultural differences in communication styles.
A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 4.5 kg (10 lb) in the past month. Which of the following is the nurse's best response in this situation?
- A. Do you own any lethal weapon?
- B. How do other people treat you?
- C. Are you feeling so hopeless that you feel like hurting yourself now?
- D. People often feel hopeless, but the feeling resolves within a few weeks.
Correct Answer: C
Rationale: The correct answer is C: "Are you feeling so hopeless that you feel like hurting yourself now?" This response directly addresses the patient's suicidal ideation and assesses the immediate risk of harm. It shows the nurse's concern for the patient's safety and allows for further evaluation and intervention if necessary.
Option A is incorrect because asking about owning a lethal weapon does not directly address the patient's current mental state and immediate risk of harm. Option B is incorrect as it focuses on external factors rather than the patient's internal feelings of hopelessness and suicidal thoughts. Option D is incorrect as it minimizes the seriousness of the patient's symptoms and may lead to overlooking the urgency of the situation.
A nurse is frequently bothered when a patient does not take the medications as prescribed until the patient speaks with her family. The nurse is so irritated by this behaviour that he often finds it hard to provide appropriate care to this individual. What should the nurse do first in trying to overcome his difficulty?
- A. Identify the meaning of family inclusion to the patient
- B. Understand that this is a cultural practice that is helpful to the patient
- C. Allow the patient to take her medications only when she feels comfortable
- D. Discuss with the patient the importance of independent health decisions
Correct Answer: B
Rationale: Step 1: Recognize Cultural Sensitivity - Understanding that family inclusion is a cultural practice is crucial as it helps the nurse appreciate the patient's perspective. Step 2: Empathy - Acknowledging the significance of family involvement for the patient shows empathy and respect for their beliefs and values. Step 3: Effective Communication - By recognizing and respecting the cultural practice, the nurse can build a trusting relationship with the patient and her family, leading to better adherence to medication and improved care outcomes. In summary, Option B is correct as it emphasizes cultural competence and patient-centered care. Options A, C, and D are incorrect as they do not address the core issue of cultural understanding and may hinder effective communication and relationship-building with the patient and her family.
A nurse is caring for a patient with diabetes. The nurse should monitor for which of the following complications?
- A. Hypoglycemia.
- B. Hyperkalemia.
- C. Hypotension.
- D. Hyperglycemia.
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. In diabetes, hyperglycemia occurs when blood sugar levels are too high. This can lead to various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. Monitoring for hyperglycemia is crucial to prevent these serious complications.
A: Hypoglycemia is low blood sugar and can also occur in diabetes, but it is not the primary complication to monitor for in this case.
B: Hyperkalemia is high potassium levels and is not a common complication of diabetes unless there are other underlying issues.
C: Hypotension is low blood pressure, which can be a complication of diabetes but is not as directly related to glucose management as hyperglycemia.
In summary, monitoring for hyperglycemia is essential in diabetes care to prevent serious complications associated with high blood sugar levels.
A nurse is caring for a patient with a history of chronic liver disease. The nurse should monitor for which of the following complications?
- A. Anemia.
- B. Jaundice.
- C. Hypertension.
- D. Hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.