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Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: Providing new information slowly and in small amounts to a confused individual, like Mr. Reyes, is important because confusion or delirium can be a defense mechanism against further stress. By giving information gradually, it allows the individual to better absorb and process the information without becoming overwhelmed, which can further exacerbate their confusion. This approach also helps reduce the risk of causing additional stress or agitation in the individual, thus promoting a more conducive environment for cognitive processing and understanding.
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Which assessment action will help the nurse determine if the patient with Bell's Palsy is receiving adequate nutrition?
- A. Monitor meal trays
- B. Check twice-weekly weights
- C. Measure intake and output
- D. Assess swallowing reflex
Correct Answer: D
Rationale: By assessing the patient's swallowing reflex, the nurse can determine if the patient is able to swallow food and liquids properly, which is crucial for adequate nutrition intake. Bell's Palsy can affect facial muscles, including those involved in chewing and swallowing. A impaired swallowing reflex can lead to difficulties in eating and drinking, which in turn may affect the patient's nutrition status. Monitoring meal trays (A) may not provide direct information about the patient's ability to swallow, as a patient may not be able to communicate swallowing difficulties. Checking twice-weekly weights (B) may indicate weight changes, but it may not necessarily give insight into nutrition adequacy related to swallowing ability. Measuring intake and output (C) may help track calorie intake and fluid balance, but it may not specifically address swallowing issues that can impact nutrition in a patient with Bell's Palsy. Assessing the swallowing reflex (D) directly addresses the patient's ability to consume food and
Which of the ff. descriptions by the nurse would best explain glaucoma to a patient?
- A. "There is an increase in the amount of vitreous humor."
- B. "There is an increase in the intraocular pressure."
- C. "There is a decrease in the amount of aqueous humor."
- D. "There is a decrease in the intraocular pressure."
Correct Answer: B
Rationale: Glaucoma is a group of eye conditions that damage the optic nerve, usually due to high intraocular pressure (IOP). In glaucoma, there is an imbalance between the production and drainage of aqueous humor in the eye, leading to increased pressure inside the eye. This elevated pressure can cause damage to the optic nerve, which is essential for vision, resulting in vision loss. Therefore, the best description by the nurse to explain glaucoma to a patient would be that there is an increase in intraocular pressure (Choice B).
Regarding the physical growth of middle childhood (6-11 yr), all are true EXCEPT
- A. 3-3.5 kg weight increment/yr
- B. 6-7 cm height increment/yr
- C. brain myelinization stops by 8 yr
- D. deciduous tooth falls by 6 yr
Correct Answer: C
Rationale: Brain myelinization continues beyond 8 years.
Which of the ff nursing interventions ensure that a client with Hodgkin's disease remains free of infection? Choose all that apply
- A. Apply ice to the skin for brief periods
- B. Provide cool sponge baths
- C. Practice conscientious hand washing
- D. Use cotton gloves Restrict visitors or personnel with infections from contact with the client
Correct Answer: C
Rationale: #NAME?
Nurse Carlos teaches a community adult class about the common symptoms of tuberculosis. Which of the following should Nurse Carlos include?
- A. weight loss
- B. dyspnea on exertion
- C. increased appetite
- D. mental status changes
Correct Answer: A
Rationale: Nurse Carlos should include weight loss as one of the common symptoms of tuberculosis. Unintentional weight loss is a classic symptom seen in individuals with active tuberculosis infection. This weight loss is often accompanied by other symptoms such as fever, night sweats, and fatigue. It is important for Nurse Carlos to educate the community about this symptom as it can be a key indicator for seeking medical evaluation and treatment for tuberculosis. Dyspnea on exertion, increased appetite, and mental status changes are not typically common symptoms associated with tuberculosis.