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Expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. This is referred to as:
- A. intuition.
- B. the nursing process.
- C. clinical knowledge.
- D. diagnostic reasoning.
Correct Answer: A
Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.
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A nurse is caring for a patient with hypertension. The nurse should educate the patient to avoid which of the following?
- A. Limiting caffeine intake.
- B. Consuming more fruits and vegetables.
- C. Increasing salt intake.
- D. Increasing physical activity.
Correct Answer: C
Rationale: The correct answer is C: Increasing salt intake. Salt intake can worsen hypertension by causing water retention and increasing blood pressure. Limiting caffeine intake (A) and increasing physical activity (D) are beneficial for managing hypertension. Consuming more fruits and vegetables (B) is also recommended as they are part of a healthy diet that can help lower blood pressure. Overall, educating the patient to avoid increasing salt intake is crucial in managing hypertension effectively.
Which of the following is the appropriate health promotion question to ask during a review of symptoms?
- A. "Do you use sunscreen while outside?"
- B. "I need to see if your skin is warm and dry."
- C. "Have you experienced any dizziness or headaches?"
- D. "When you cough, what colour is the sputum you bring up?"
Correct Answer: A
Rationale: The correct answer is A: "Do you use sunscreen while outside?" because it directly relates to health promotion by addressing preventive measures. Sunscreen helps prevent skin cancer and other skin conditions. Choice B is incorrect as it focuses on assessing skin condition rather than promoting health. Choice C is incorrect as it relates to symptoms rather than prevention. Choice D is incorrect as it is related to assessing a specific symptom rather than promoting overall health.
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary changes. Which of the following statements by the patient indicates proper understanding?
- A. I should limit my intake of foods high in potassium and phosphorus.
- B. I should increase my fluid intake to stay hydrated.
- C. I can eat as much protein as I want to promote healing.
- D. I should drink more sodas for hydration.
Correct Answer: A
Rationale: The correct answer is A. In CKD, limiting potassium and phosphorus intake is crucial to prevent electrolyte imbalances and further kidney damage. Excessive protein intake can worsen kidney function, so the patient should not eat as much protein as they want. Increasing fluid intake is beneficial for hydration, but sodas are not recommended due to their high sugar and phosphorus content, which can be harmful for CKD patients. Therefore, option A is the best choice for proper understanding of dietary changes in CKD.
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this a normal finding, and proceed with the abdominal assessment.
- C. Use less force to percuss over the abdomen.
- D. Use more force to percuss over the abdomen.
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
While auscultating for heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
- A. Document the findings on the patient's record.
- B. Wait 10 minutes, and auscultate the heart again.
- C. Ask another nurse to double-check the finding.
- D. Ask the patient to take deep breaths and check for changes in their physical condition.
Correct Answer: A
Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.