Nokea
The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
- A. I know that my name is John. I couldn't tell you where I am. I think this year is 2009, though.
- B. I know that my name is John, but to tell you the truth, I get kind of confused about the date.
- C. I know that my name is John; I guess I'm at the hospital in Victoria. No, I don't know the date.
- D. I know that my name is John. I am at the hospital in Victoria. I couldn't tell you what date it is, but I know that it is February of a new year"”2009.
Correct Answer: D
Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains.
Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.
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A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which of the following would be an appropriate response by the nurse?
- A. "How does your family react to your pain?"
- B. "That must be terrible. You probably pinched a nerve."
- C. "I've had back pain myself, and I know it can be excruciating."
- D. "How would you say the pain affects your ability to carry on your daily activities?"
Correct Answer: D
Rationale: The correct answer is D because it focuses on assessing the impact of the pain on the woman's daily activities, which is crucial in understanding the severity and functional limitations caused by the pain. This helps in planning appropriate interventions and evaluating the effectiveness of treatment.
Choice A is incorrect as it shifts the focus to the family's reaction rather than the woman's pain. Choice B is incorrect as it assumes a diagnosis without proper assessment and may minimize the woman's experience. Choice C is incorrect as it redirects the conversation to the nurse's experience, which is not helpful in addressing the woman's pain and needs.
Which disease is least likely to be associated with increased potential for bleeding?
- A. metastatic liver cancer
- B. gram-negative septicemia
- C. pernicious anemia
- D. iron-deficiency anemia
Correct Answer: C
Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.
A 32-year-old patient shares with the nurse that she has been unwell for 2 weeks. She has had a variety of symptoms and has been treating them with herbs that her mother has provideThe nurse should:
- A. tell the patient that it is the herbs that are making her feel unwell.
- B. ask the patient more about the effects of the herbs.
- C. take a sample of the herbs to send to the laboratory for analysis.
- D. ask the patient's mother to explain the use of the herbs.
Correct Answer: B
Rationale: The correct answer is B because the nurse needs more information to assess the situation effectively. By asking the patient more about the effects of the herbs, the nurse can gather crucial details about the patient's condition and the potential impact of the herbs on her health. This will help the nurse make an informed decision on the appropriate course of action.
Choice A is incorrect because jumping to conclusions without gathering more information can be detrimental to the patient's care. Choice C is incorrect as sending the herbs for analysis may not provide immediate insights into the patient's condition. Choice D is incorrect as the focus should be on directly obtaining information from the patient rather than involving a third party.
A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to enjoy doing.' He also says that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, which of the following questions should the nurse ask him?
- A. Has there been any change in your weight?
- B. Are you having any thoughts of suicide?
- C. How long have you been feeling this way?
- D. Are you having feelings of worthlessness?
Correct Answer: C
Rationale: Rationale: The correct answer is C: "How long have you been feeling this way?" This question is essential to differentiate between dysthymic disorder and major depressive disorder. In dysthymic disorder, symptoms persist for at least 2 years, whereas in major depressive disorder, symptoms typically last for at least 2 weeks. By asking how long the patient has been feeling this way, the nurse can determine the duration of the symptoms and make a more accurate diagnosis.
Summary of other choices:
A: "Has there been any change in your weight?" This question is more relevant to assessing changes in appetite, which can be a symptom of depression, but it does not differentiate between dysthymic and major depressive disorders.
B: "Are you having any thoughts of suicide?" While important to assess for safety, this question does not help differentiate between the two disorders.
D: "Are you having feelings of worthlessness?" This question is relevant to assessing symptoms of depression but does not
When listening to a patient's breath sounds, the nurse is unsure about a sound that is hearThe nurse should:
- A. notify the patient's physician immediately.
- B. document the sound exactly as it was heard.
- C. validate the data by asking a colleague to listen to the breath sounds.
- D. assess again in 20 minutes to note whether the sound is still present.
Correct Answer: C
Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.