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The nurse is performing a health assessment on a 16-year-old girl, who has been brought to the clinic by her parents. Which of the following instructions would be appropriate for the parents before the interview begins?
- A. "Please stay with your daughter during the interview; you can answer for her if she is not able to."
- B. "It would help to interview the three of you together."
- C. "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?"
- D. "While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?"
Correct Answer: D
Rationale: The correct answer is D because it respects the girl's privacy and allows her to speak freely without parental influence. By asking the parents to step out, the nurse creates a safe space for the girl to discuss any sensitive issues. Choice A may inhibit the girl's honest communication. Choice B risks the parents dominating the conversation. Choice C may make the girl uncomfortable discussing personal matters in front of her parents.
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A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train.' What is the best way for the nurse to communicate with this patient?
- A. Use speech because he will understand even if the nurse cannot understand him.
- B. Abandon all attempts to communicate with him. His aphasia is irreversible.
- C. Give him a pencil and paper because reading and writing abilities will not be impaired.
- D. Support his efforts to communicate, and use pantomime and gestures to communicate when possible.
Correct Answer: D
Rationale: The correct answer is D because the patient is showing signs of expressive aphasia, where they have difficulty with verbal expression. By supporting his efforts to communicate and using pantomime and gestures, the nurse can help bridge the communication gap and facilitate understanding. This approach acknowledges the patient's drive to communicate and helps him convey his thoughts effectively.
Option A is incorrect because although the patient may understand, the nurse needs to adapt the communication method to support the patient's expressive difficulties. Option B is incorrect as abandoning communication efforts would be detrimental to the patient's well-being and recovery. Option C is incorrect as the patient's ability to read and write may also be impaired due to the stroke, making this method less effective than using gestures and pantomime.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse would expect to find which of the following?
- A. Anasarca.
- B. Scleroderma.
- C. Pedal erythema.
- D. Clubbing of the nails.
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.
In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:
- A. last glaucoma examination.
- B. frequency of breast self-examination.
- C. date of her last electrocardiogram.
- D. limitations related to her involvement in sports activities.
Correct Answer: D
Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.
When a nurse is assessing a patient's pain level, which of the following questions would be most appropriate?
- A. "How would you rate your pain on a scale from 0 to 10?"
- B. "When did your pain start?"
- C. "What causes your pain?"
- D. "Do you need any medication for the pain?"
Correct Answer: A
Rationale: Step 1: Asking the patient to rate pain on a scale of 0 to 10 is a standard pain assessment tool, allowing for quantification and tracking of pain intensity.
Step 2: This question helps in understanding the severity of pain objectively.
Step 3: It provides a baseline for further pain management interventions.
Step 4: Other choices are incorrect as they do not directly address assessing pain intensity or severity.
Summary: Option A is the most appropriate as it focuses on quantifying pain, which is crucial for effective pain management. Choices B, C, and D are not as relevant for assessing pain intensity.
A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
- A. Severe headache
- B. Dehydration
- C. Respiratory depression
- D. Sudden loss of vision
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.