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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 because conducting the interview in a quiet environment, such as the waiting area with the television turned off, minimizes background noise and distractions for a patient with a hearing deficit. This setting allows for better communication and ensures that the patient can hear and understand the nurse clearly.
A: Conducting the interview in the patient's room with the door closed may still have background noise from the hallway or other rooms.
C: Conducting the interview before administration of pain medication is not relevant to improving communication for a patient with a hearing deficit.
D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional noise and distractions, making it difficult for the patient to focus on the conversation.
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Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?
- A. Increased urine output
- B. Dyspnea on exertion
- C. Swollen joints
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
- A. patients.” “If the nursing department uses this system, communication among nurses who work
- B. throughout the hospital may be enhanced.” “We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our
- C. unit.” “The NIC system provides one way to improve safe and effective documentation in the
- D. hospital’s electronic health record.”
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
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.
Usually, how does the patient behave after his seizure has subsided?
- A. Most comfortable walking and moving about
- B. Sleeps for a period of time
- C. Becomes restless and agitated
- D. Say he is thirsty and hungry
Correct Answer: B
Rationale: The correct answer is B: Sleeps for a period of time. After a seizure, the brain and body experience fatigue and exhaustion. It is common for the patient to feel drowsy and require rest to recover. This post-ictal state is characterized by sleepiness and confusion. The other choices are incorrect because typically, after a seizure, the patient is not most comfortable walking and moving about (A), does not become restless and agitated (C), and may not immediately express thirst and hunger (D). It is important to ensure the patient is in a safe environment and allow them to rest after a seizure episode.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
- A. Helping the client cope with body image
- B. Maintaining a patent airway.
- C. Preventing injury.
- D. Ensuring adequate nutrition.
Correct Answer: B
Rationale: The correct answer is B: Maintaining a patent airway. This is the highest priority because the client with esophageal cancer is at risk for airway obstruction due to difficulty swallowing. Maintaining a patent airway ensures adequate oxygenation and ventilation, which are vital for the client's survival. Without a clear airway, the client may experience respiratory distress or failure. Body image, preventing injury, and ensuring adequate nutrition are important aspects of care but do not take precedence over maintaining a patent airway in this situation.