Nokea
It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is:
- A. "Are you bored?"
- B. "It is 10 o'clock.".
- C. "Why do you ask?"
- D. "Guess, what time is it?"
Correct Answer: B
Rationale: The nurse's appropriate response is to provide the requested information clearly and directly. In this case, the client asked for the time, so the best response is to say "It is 10 o'clock" to answer their question promptly. Options A, C, and D do not address the client's question and may be perceived as dismissive or unhelpful.
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A patient presents with a painful, vesicular rash in a dermatomal distribution on the left thorax. The patient reports a history of chickenpox during childhood. Which of the following conditions is most likely responsible for this presentation?
- A. Herpes simplex virus infection
- B. Herpes zoster (shingles)
- C. Varicella (chickenpox)
- D. Impetigo
Correct Answer: B
Rationale: The presentation of a painful, vesicular rash in a dermatomal distribution on the left thorax, specifically in a patient with a history of chickenpox, is most suggestive of herpes zoster, commonly known as shingles. Herpes zoster is caused by the reactivation of the varicella-zoster virus, the same virus responsible for chickenpox. After a person recovers from chickenpox, the virus remains dormant in the nerve cells and can reactivate years later to cause shingles. The rash in herpes zoster typically progresses through different stages, including red patches leading to fluid-filled blisters. The characteristic rash typically appears unilaterally and is usually preceded by pain, burning, or tingling in the affected area. Unlike herpes simplex virus infection, which can cause similar lesions but is not typically localized to a specific dermatome, herpes zoster presents as a distinct unilateral cluster of vesicles along
Before finishing the check up, which of the following principles is NOT included among the principles of guidance in handling Richard?
- A. Controlling temper tantrums
- B. Basing her expectations within the child's limitations.
- C. Acceptance of masturbation as a normal phenomenon to be discouraged in public.
- D. Reinforcing the correct use of language.
Correct Answer: D
Rationale: The principles of guidance in handling Richard involve understanding and addressing the behaviors and needs of the child, such as controlling temper tantrums, basing expectations within the child's limitations, and acceptance of certain behaviors like masturbation as normal but to be discouraged in public. However, reinforcing the correct use of language is not typically included as a principle specifically in handling Richard. Therefore, this choice is NOT included among the principles of guidance in this context.
A patient presents with sudden-onset, severe eye pain, headache, nausea, and vomiting. On examination, the affected eye appears red, with a steamy cornea and mid-dilated, non-reactive pupil. Which of the following conditions is most likely responsible for this presentation?
- A. Acute angle-closure glaucoma
- B. Central retinal artery occlusion
- C. Optic neuritis
- D. Corneal ulcer
Correct Answer: A
Rationale: The presentation described is consistent with acute angle-closure glaucoma. This condition typically presents with sudden-onset severe eye pain, headache, nausea, and vomiting. On examination, the affected eye appears red, with a steamy cornea due to corneal edema and a mid-dilated, non-reactive pupil due to pupillary block from the forward displacement of the iris. Acute angle-closure glaucoma is considered a medical emergency as it can lead to permanent vision loss if not promptly treated. Prompt management involves reducing intraocular pressure to prevent further damage to the optic nerve.
A nurse is caring for a patient with limited English proficiency. What action should the nurse take to ensure effective communication with the patient?
- A. Speak loudly and slowly to help the patient understand
- B. Use medical jargon to convey information more efficiently
- C. Obtain interpreter services or language assistance as needed
- D. Ignore the patient's language barriers and focus on nonverbal communication
Correct Answer: C
Rationale: The nurse should obtain interpreter services or language assistance as needed to ensure effective communication with a patient who has limited English proficiency. Using an interpreter will facilitate clear and accurate communication between the nurse and the patient, enabling the patient to fully understand their care, treatment, and any instructions provided. Speaking loudly or slowly, using medical jargon, or ignoring the language barriers are not effective strategies for communicating with a patient who has limited English proficiency. Utilizing interpreter services demonstrates respect for the patient's language and cultural needs, which is essential for providing high-quality care.
What IMMEDIATE danger should the nurse anticipate post Transurethral Resection of the Prostate (TURP)?
- A. Infection
- B. Thrombosis
- C. Bleeding
- D. Shock
Correct Answer: C
Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.