Nokea
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B: The waiting area with the television turned off. This choice eliminates potential distractions, allowing the patient with a hearing deficit to focus on the interview. Noise from the television can interfere with communication. Other choices are incorrect because: A) The closed door may block out external noise, but the patient's room could still have distractions. C) Administering pain medication can affect the patient's alertness and ability to communicate effectively. D) The waiting room with occupational therapy activities can be noisy and distracting. Conducting the interview in a quiet waiting area ensures optimal communication and understanding.
You may also like to solve these questions
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
- A. Verbalizes fears
- B. Demonstrates leg exercises
- C. Maintains skin integrity
- D. Explains deep breathing exercises
Correct Answer: C
Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.
When caring for Mr. Reyes, the nurse should assess for
- A. Decreased carotid pulses
- B. Altered level of consciousness
- C. Bleeding from oral cavity
- D. Absence of deep tendon-reflexes
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues.
A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario.
C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness.
D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.
Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
- A. Kaposi's Sarcoma
- B. Pneumonia Carnii
- C. Filterable Virus
- D. Staphylococcus bacteria
Correct Answer: B
Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.
While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client’s chart. Which of the following actions clearly demonstrates assessing?
- A. The nurse bathing the client
- B. The nurse documenting the incident
- C. The nurse asking if the client is having pain
- D. The nurse removing the wash basin
Correct Answer: C
Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being.
A: The nurse bathing the client is not an action of assessment but rather a task related to providing care.
B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition.
D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
- A. Make sure he drinks 8 glasses of water a day.
- B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
- C. Look for signs of hyperchloremia
- D. Observe for neurologic changes
Correct Answer: B
Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications.
A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances.
C: Hyperchloremia is not a common concern in this scenario based on the given lab values.
D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.