The medical-surgical nurse performs a dressing change on a patient with a history of non-insulin-dependent diabetes. The patient questions why the wound is not healing. Recognizing a teaching opportunity, what response does the nurse offer the patient?
- A. Are you eating enough carbohydrates in your diet?
- B. Have you limited your exercise because of the wound?
- C. How much sleep are you getting at night?
- D. How often do you check your blood sugar levels at home?
Correct Answer: D
Rationale: Blood sugar control significantly impacts wound healing in diabetic patients.
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When assessing the health beliefs and practices of an older Hispanic adult, the nurse observes that the client uses a traditional folk healer to manage health problems. How would you respond?
- A. Respectfully acknowledge the practice and integrate it where possible.
- B. Discredit the folk healer's methods.
- C. Insist on conventional medical treatment only.
- D. Ignore the client's preference.
Correct Answer: A
Rationale: Respecting and integrating traditional practices fosters trust and collaboration in care delivery.
How should the nurse respond to Mrs. West’s statement, “Oh well, I have already lived my life anyway.”
- A. “Oh, you have nothing to worry about Mrs. West. We’re going to take good care of you.”
- B. “You feel that your life is ending, Mrs. West? Can you tell me more about your feelings?”
- C. “Your doctor is one of the best and our surgical staff is excellent.”
- D. “The x-rays indicate that your tumor is accessible and the surgery will cure your problem.”
Correct Answer: B
Rationale: Encouraging the patient to express feelings fosters trust and understanding.
A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?
- A. Patency of the intravenous line
- B. Level of pain
- C. Integrity of the dressing
- D. Need for suctioning
Correct Answer: D
Rationale: The correct answer is D: Need for suctioning. After a laryngectomy, maintaining a clear airway is crucial to prevent aspiration and ensure proper oxygenation. Suctioning helps remove secretions and maintain airway patency. Monitoring for signs of respiratory distress is essential.
A: Patency of the intravenous line is important but not the priority over airway management.
B: Level of pain is important but not as critical as ensuring a clear airway.
C: Integrity of the dressing is important for wound healing but does not directly impact airway patency.
Appropriate treatment for a patient with cellulitis includes
- A. Petrolatum and vitamin A and D ointment.
- B. Antibiotics, such as cephalexin, and over-the-counter analgesics.
- C. Weight-bearing exercises and diuretics, such as furosemide.
- D. Wet to dry dressings and steroids.
Correct Answer: B
Rationale: Antibiotics are the mainstay of treatment for cellulitis.
What is the definition of substance abuse?
- A. A compulsive need to experience pleasure
- B. Behavior associated with maintaining an addiction
- C. Absence of a substance will cause withdrawal symptoms
- D. Overuse and dependence on a substance that negatively affects functioning.
Correct Answer: D
Rationale: Substance abuse involves overuse and dependence on a substance leading to negative impacts on one's life, encompassing both physical and social consequences.