Nokea
In trying to communicate with a client with cerebral vascular accident (stroke) and aphasia, which of the following actions by the nurse would be least helpful to the client?
- A. Speaking to the client at a slower rate.
- B. Allowing plenty of time for the client to respond.
- C. Completing the sentences that the client cannot finish.
- D. Looking directly at the client during attempts at speech.
Correct Answer: C
Rationale: The correct answer is C because completing the client's sentences does not promote their communication skills development. It can be frustrating for the client and may hinder their progress in regaining speech abilities. A is correct because speaking slowly can help the client understand better. B is correct as it gives the client time to process and respond. D is correct as maintaining eye contact can enhance communication and show respect. Completing the client's sentences should be avoided as it undermines their autonomy and potential for improvement.
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During auscultation, the nurse hears an unfamiliar sound. The best action is to:
- A. Ignore it if the patient is asymptomatic.
- B. Ask another nurse to double-check the finding.
- C. Document the sound and continue the assessment.
- D. Reposition the patient and listen again.
Correct Answer: B
Rationale: The correct answer is B because asking another nurse to double-check the finding is crucial for validation and ensuring accuracy in assessment. This step helps in confirming the unfamiliar sound and ruling out any potential errors or misinterpretations. It promotes patient safety and effective communication among healthcare providers.
Ignoring the sound (Choice A) can lead to overlooking a significant finding that may impact the patient's condition. Documenting and continuing the assessment (Choice C) without validation may result in incomplete information and potential misdiagnosis. Repositioning the patient and listening again (Choice D) may not address the need for confirmation from another healthcare provider.
The nurse is preparing to assess a patient's blood pressure. Which action is essential for obtaining an accurate reading?
- A. Positioning the patient's arm above the level of the heart.
- B. Using a cuff that covers two-thirds of the patient's upper arm.
- C. Deflating the cuff at a rate of 5-10 mm Hg per second.
- D. Having the patient stand during the measurement.
Correct Answer: B
Rationale: The correct answer is B: Using a cuff that covers two-thirds of the patient's upper arm. This is essential for obtaining an accurate blood pressure reading because using a cuff that is too small can result in falsely elevated readings, while using a cuff that is too large can result in falsely low readings. By covering two-thirds of the upper arm, the cuff ensures proper compression of the brachial artery, allowing for an accurate measurement.
A: Positioning the patient's arm above the level of the heart is not essential for obtaining an accurate reading and can lead to inaccurate results.
C: Deflating the cuff at a rate of 5-10 mm Hg per second is important but not as crucial as using the correct cuff size.
D: Having the patient stand during the measurement is not recommended as blood pressure should be measured with the patient in a seated or lying position for accuracy.
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
- A. The best time to perform BSE is in the middle of the menstrual cycle.
- B. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue.
- C. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.
- D. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born.
Correct Answer: C
Rationale: The correct answer is C because it states the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. This timing ensures that the breasts are least likely to be swollen or tender due to hormonal changes, making it easier to detect abnormalities.
A is incorrect because performing BSE in the middle of the menstrual cycle may coincide with hormonal fluctuations that could affect breast tissue. B is incorrect because performing BSE bimonthly may lead to missed changes in the breast. D is incorrect because pregnancy does not preclude a woman from performing BSE; in fact, it is important for pregnant women to monitor their breast health.
The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:
- A. Is most likely a benign sebaceous cyst.
- B. Is most likely a keloid.
- C. Could be a potential carcinoma, and the patient should be referred for a biopsy.
- D. Is a tophus, which is common in the older adult and is a sign of gout.
Correct Answer: C
Rationale: The correct answer is C because the presence of a crusty nodule that intermittently bleeds, does not heal, and has an ulcerated crusted appearance with an indurated base raises suspicion for potential carcinoma. This presentation is concerning for skin cancer, specifically a squamous cell carcinoma or basal cell carcinoma. Therefore, the patient should be referred for a biopsy to confirm the diagnosis and initiate appropriate treatment.
Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a painless, mobile, smooth nodule, a keloid (B) is characterized by an overgrowth of scar tissue and is not associated with the described symptoms, and a tophus (D) is a deposit of uric acid crystals seen in gout, which would present differently than the described ulcerated crusted nodule.
Hypothermia is defined as ...
- A. An increase in body temperature over 96.8°
- B. A drop in body temperature below 96.8°
- C. Cyanosis
- D. None of the above
Correct Answer: B
Rationale: Hypothermia is a core temperature below 95°F (35°C), but 96.8°F (36°C) is a practical threshold for early detection . An increase over 96.8°F suggests normothermia or fever. Cyanosis is a symptom, not hypothermia. ‘None' is incorrect. Choice B is correct, aligning with nursing definitions (e.g., CDC) where subnormal temperature signals risk, guiding interventions like warming to prevent complications.