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In order to determine the patient's ability to concentrate and focus, which would be the PRIORITY nursing action?
- A. Asked for the academic performance
- B. Conduct paper and pencil test
- C. Assess the mental status of the patient
- D. Refer the patient to the psychiatrist
Correct Answer: C
Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.
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A patient in the intensive care unit (ICU) develops acute respiratory distress syndrome (ARDS) characterized by hypoxemia and bilateral pulmonary infiltrates. What intervention should the healthcare team prioritize to manage the patient's condition?
- A. Initiate mechanical ventilation with low tidal volume strategy.
- B. Administer intravenous fluids to maintain hemodynamic stability.
- C. Prescribe broad-spectrum antibiotics for suspected pneumonia.
- D. Perform chest physiotherapy to promote airway clearance.
Correct Answer: A
Rationale: Acute Respiratory Distress Syndrome (ARDS) is a severe form of acute lung injury that is characterized by hypoxemia, bilateral pulmonary infiltrates, and noncardiogenic pulmonary edema. When managing a patient with ARDS in the ICU, the priority intervention is to provide adequate oxygenation and ventilation. Mechanical ventilation is often necessary to support gas exchange in these patients.
A patient presents with episodic throbbing headache associated with nausea, vomiting, and sensitivity to light and sound. Symptoms are often preceded by an aura. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Migraine headache
- B. Cluster headache
- C. Tension-type headache
- D. Chronic daily headache
Correct Answer: A
Rationale: The patient's presentation of episodic throbbing headache associated with nausea, vomiting, sensitivity to light and sound, and aura suggests a diagnosis of migraine headache. Migraines are a common neurological condition characterized by recurrent moderate to severe headaches that are often unilateral, pulsating, and aggravated by physical activity. The presence of premonitory symptoms (aura) before the headache is a key feature commonly seen in migraines. Additionally, nausea, vomiting, and sensitivity to light and sound are also common features associated with migraines.
What response should the nurse use in dealing with this behavior?
- A. Encourage her to scrub the doorknobs with a strong antiseptic so she does not need to use tissue papers.
- B. Supply her with paper tissue to help her function until her anxiety is reduced .
- C. Force her to touch doorknobs by removing all available paper tissue until she learns to deal with the situation.
- D. Explain to her that ideas about doorknobs with covid 19 are part of the i1lness and is not necessary.
Correct Answer: B
Rationale: Supplying the patient with paper tissues to use when touching doorknobs is the most appropriate response in this situation. This action acknowledges and respects the patient's anxiety while providing a practical solution to help her cope. Forcing her to touch doorknobs or discouraging her concerns would not address the underlying anxiety and may lead to increased distress. Encouraging her to scrub doorknobs with a strong antiseptic is not necessary and may exacerbate her anxiety. Explaining that her concerns are part of her illness may invalidate her feelings and is not a constructive way to address the situation. Supplying her with paper tissues allows her to feel more comfortable while still being able to navigate her daily activities.
In healthcare facility, a planned program of loss prevention and liability control refers to
- A. quality assurance
- B. risk management
- C. critical pathways
- D. peer review
Correct Answer: B
Rationale: Risk management in a healthcare facility involves identifying, assessing, and minimizing risks to prevent potential harm to patients and reduce liability issues. A planned program of loss prevention and liability control falls under the umbrella of risk management. This program includes strategies to mitigate risks such as patient safety protocols, infection control measures, staff training, and proper documentation practices to minimize legal liabilities. By implementing risk management practices, healthcare facilities aim to provide safe and high-quality care to their patients while also protecting themselves against potential legal challenges.
To be more responsible, a nurse needs to understand the elements of the communication process. When she initiates interpersonal communication, the element involved is
- A. referent
- B. message
- C. sender
- D. channel
Correct Answer: C
Rationale: The element involved when a nurse initiates interpersonal communication is the sender. In the communication process, the sender is the person who initiates the message or information to be conveyed to the receiver. In this case, the nurse is taking on the role of the sender by initiating the communication with the patient, another healthcare professional, or any other individual. The sender is responsible for encoding the message and selecting the appropriate channel to convey it effectively. Therefore, in this scenario, the nurse is the one initiating communication, making her the sender in the communication process.