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Priority Decision: The nurse prepares to interview a patient for a nursing history but finds the patient in obvious pain. Which action by the nurse is the best at this time?
- A. Delay the interview until the patient is free of pain.
- B. Administer pain medication before initiating the interview.
- C. Gather as much information as quickly as possible by using closed questions that require brief answers.
- D. Ask only those questions pertinent to the specific problem and complete the interview when the patient is more comfortable.
Correct Answer: A
Rationale: The correct answer is 'Delay the interview until the patient is free of pain.' Pain can interfere with concentration and communication, making it difficult for the patient to provide accurate information. Delaying the interview ensures better quality data collection once the patient is comfortable.
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Following treatment with fluoxetine, a selective serotonin reuptake inhibitor for depression, Mary hardly sleeps, is hyperactive, easily distracted, and appears elated. You would expect her physician to
- A. Continue the selective serotonin reuptake inhibitor.
- B. Start a mood stabilizer.
- C. Switch to a tricyclic antidepressant.
- D. Add a monoamine oxidase inhibitor.
Correct Answer: B
Rationale: Mood stabilizers are used to treat symptoms of mania or hypomania associated with bipolar disorder.
What should govern the nurse’s actions regarding Mr. West rubbing Mrs. West’s calf?
- A. Touch is an important method of communication
- B. It is important to involve family members in patient care
- C. Massage increases circulation, therefore reducing tenderness
- D. A thrombus becomes an embolus when dislodged
Correct Answer: D
Rationale: Massaging the leg could dislodge a clot, leading to complications.
Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do?
- A. Assess their understanding of what hospice care services are.
- B. Ask them how they will care for the patient without hospice care.
- C. Talk directly to the patient and family to see if she can change their minds.
- D. Accept their decision since they are Hispanic and prefer to care for their own.
Correct Answer: A
Rationale: The nurse should assess their understanding of hospice care services to ensure they are making an informed decision based on accurate information rather than assumptions or cultural biases.
The first priority to care for the patient with a new fracture includes assessing
- A. Respiratory rate and effort, as well as pulse.
- B. The fracture site for bleeding.
- C. For signs of infection at the wound site of an open fracture.
- D. For circulation and sensation distal to the fracture site.
Correct Answer: D
Rationale: Assessing circulation and sensation ensures no compromise to distal structures.
During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?
- A. Dysphagia
- B. Hoarseness
- C. Dyspnea
- D. Weight loss
Correct Answer: B
Rationale: The correct answer is B: Hoarseness. Hoarseness is a common early manifestation of laryngeal cancer due to vocal cord involvement. Smoking is a major risk factor for laryngeal cancer. Dysphagia (choice A) is more commonly associated with esophageal cancer. Dyspnea (choice C) is usually a late manifestation of laryngeal cancer when it causes airway obstruction. Weight loss (choice D) may occur later in the disease progression but is not typically an early sign. Thus, hoarseness is the most likely early manifestation due to its direct connection to the vocal cords and smoking history.