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The nurse is performing a review of systems on a 76-year-old patient. Which of the following statements is correct for this situation?
- A. The questions asked are identical for all ages.
- B. The interviewer will start incorporating different questions for patients 70 years of age and older.
- C. Additional questions are reflective of the normal effects of aging.
- D. At this age, a review of systems is not necessary; just focus on current problems.
Correct Answer: C
Rationale: Rationale: Choice C is correct as additional questions in a review of systems for a 76-year-old patient should address age-related changes. This allows for better assessment of potential health issues specific to older adults. Choice A is incorrect as questions may vary based on age. Choice B is incorrect as age alone does not dictate question changes. Choice D is incorrect as a review of systems is important at all ages for comprehensive patient assessment.
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A nurse is caring for a patient with a history of myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administering pain medication.
- B. Monitoring vital signs and oxygen saturation.
- C. Encouraging deep breathing exercises.
- D. Providing nutritional education.
Correct Answer: B
Rationale: The correct answer is B: Monitoring vital signs and oxygen saturation. This is the priority intervention because it allows the nurse to assess the patient's current cardiac status and detect any potential complications early. Monitoring vital signs provides crucial information on the patient's cardiovascular stability, while oxygen saturation levels indicate adequate tissue perfusion. Administering pain medication (A) can be important but not the priority. Deep breathing exercises (C) and providing nutritional education (D) are important but not as immediate as monitoring vital signs and oxygen saturation in a patient with a history of myocardial infarction.
The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess skin temperature?
- A. Palpation
- B. Auscultation
- C. Inspection
- D. Use of a thermometer
Correct Answer: A
Rationale: The correct answer is A: Palpation. Palpation involves using the hands to touch and feel the skin to assess its temperature accurately. This technique allows the nurse to detect variations in temperature more effectively compared to visual inspection (Choice C) or listening with a stethoscope (Choice B). Using a thermometer (Choice D) may also provide a precise measurement, but palpation allows for a more comprehensive assessment of skin temperature by considering factors such as localized warmth or coolness.
The nurse is assessing mental health in children. Which of the following statements is true?
- A. All aspects of mental health in children are interrelated.
- B. Children are highly labile and unstable until the age of 2 years.
- C. Until the age of 7 years, children's mental health is largely a function of their parents' mental health.
- D. Children's mental health is impossible to assess until they develop the ability to concentrate.
Correct Answer: A
Rationale: The correct answer is A because all aspects of mental health in children are indeed interrelated. Mental health encompasses various components such as emotional, social, and psychological well-being, which are interconnected and influence each other. Understanding and assessing mental health in children require considering the holistic picture.
Choice B is incorrect because children are not inherently labile and unstable until the age of 2 years. Choice C is incorrect as children's mental health is influenced by various factors beyond just their parents' mental health. Choice D is incorrect because mental health assessment in children can be done using age-appropriate methods even before they develop the ability to concentrate.
Which of the following best describes a proficient nurse?
- A. A nurse who has little experience with a specified population and uses rules to guide performance
- B. A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution
- C. A nurse who sees actions in the context of daily plans for patients
- D. A nurse who sees a patient's situation as a whole, with long-term goals for the patient, rather than as a list of tasks to be performed
Correct Answer: D
Rationale: The correct answer is D because a proficient nurse should have a holistic view of the patient's situation, focusing on long-term goals rather than just completing tasks. This approach ensures comprehensive care and better outcomes. Choice A is incorrect as it implies reliance on rules over experience. Choice B is incorrect because intuition alone may not always lead to the best solution. Choice C is incorrect as it emphasizes daily plans rather than long-term goals.
A 16-year-old boy has just been admitted for overnight observation after being in an automobile accident. What is the nurse's best approach to communicating with him?
- A. Use periods of silence to communicate respect for him.
- B. Be totally honest with him, even if the information is unpleasant.
- C. Tell him that everything that is discussed will be kept totally confidential.
- D. Use slang language when possible to help him open up.
Correct Answer: B
Rationale: The correct answer is B: Be totally honest with him, even if the information is unpleasant. This is the best approach because honesty builds trust and credibility, crucial in a healthcare setting. It allows the teenager to make informed decisions about his care and fosters a therapeutic relationship.
Explanation for why the other choices are incorrect:
A: Using periods of silence may be misinterpreted as indifference or lack of engagement.
C: Promising total confidentiality may not be feasible in healthcare settings and could lead to potential harm if critical information needs to be shared with others for the patient's safety.
D: Using slang language may come across as unprofessional and may hinder effective communication and understanding between the nurse and the patient.