Nokea
The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?
- A. Slope of the earpieces should point forward toward the examiner's nose.
- B. It blocks out extraneous room noise but does not magnify sound.
- C. The tubing length should be 14 to 18 inches to prevent sound distortion.
- D. Both fit and quality of the stethoscope are important.
Correct Answer: B
Rationale: The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice. Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.
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What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
- A. Will comply with the treatment prescribed.
- B. Has given up her belief in naturalistic causes of disease.
- C. May also be seeking the assistance of a shaman or medicine man.
- D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
Correct Answer: C
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.
During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?
- A. Wash hands and then contact the physician.
- B. Continue to examine the ulceration and then wash hands.
- C. Wash hands, put on gloves, and continue with the examination of the ulceration.
- D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.
Correct Answer: C
Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.
The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?
- A. Avoid palpating reportedly “tender†areas as this may cause pain.
- B. Palpate tender areas quickly to minimize patient discomfort.
- C. Initiate the assessment with deep palpation while encouraging the patient to relax and take deep breaths.
- D. Begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch.
Correct Answer: D
Rationale: The correct approach is to begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch. This allows the nurse to first assess surface features before proceeding to deeper palpation. Starting with light palpation also helps the patient become more comfortable with being touched, creating a smoother examination experience. Palpating tender areas quickly, as suggested in choice B, can increase patient discomfort. Deep palpation, as in choice C, is typically performed after light palpation to avoid discomfort and ensure proper assessment. Avoiding palpation of tender areas first, as in choice A, helps prevent causing unnecessary pain and should be done towards the end of the assessment.
During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality?
- A. "Is a personal search to discover a supreme being."?
- B. "Is an organized system of beliefs concerning the cause, nature, and purpose of the universe."?
- C. "Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife."?
- D. "Focuses on a connection with something bigger than oneself and a belief in transcendence."?
Correct Answer: D
Rationale: Spirituality is a broad term that focuses on a connection with something greater than oneself and a belief in transcendence. It is a personal journey that arises from unique life experiences and the individual's quest to find purpose and meaning in life. The correct answer emphasizes the essence of spirituality, which involves seeking a connection with a higher power and believing in transcendence. Choices A, B, and C, on the other hand, define aspects of religion rather than spirituality. Choice A refers to a personal search for a supreme being, which is more aligned with religious beliefs. Choice B describes an organized system of beliefs about the universe, typically associated with religion. Choice C pertains to beliefs about existence after death, such as reincarnation or the afterlife, which are often religious concepts. Therefore, the best description of spirituality is focusing on a connection with something beyond oneself and a belief in transcendence.
While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do?
- A. Consider this a normal finding
- B. Palpate this area for an underlying mass
- C. Reposition the hands and attempt to percuss in this area again
- D. Consider this finding as abnormal and refer the patient for additional treatment
Correct Answer: A
Rationale: When percussing over relatively dense organs, such as the liver or spleen, a dull sound is a normal finding due to the organ's density. This occurs because the sound waves produced by tapping on the organ travel through the dense tissue, resulting in a dull sound. Therefore, the correct action for the nurse in this scenario is to consider a dull sound over the liver as a normal finding. Palpating for an underlying mass (Choice B) is not indicated based on the percussion finding alone. Repositioning the hands and repeating the percussion (Choice C) may not change the dull sound over the liver. Referring the patient for additional treatment (Choice D) without understanding the normal percussion findings over the liver would be premature. Thus, the most appropriate action is to interpret the dull sound as a normal finding.