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The nurse is taking a patient's family history. Important diseases or problems to ask the patient about include:
- A. emphysema.
- B. head trauma.
- C. mental health issues.
- D. fractured bones.
Correct Answer: C
Rationale: The correct answer is C: mental health issues. When taking a family history, mental health issues are important as they can have a genetic component and can impact the patient's overall health. Emphysema (A) is a respiratory condition, head trauma (B) is not typically hereditary, and fractured bones (D) are usually due to accidents or osteoporosis, not genetic.
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A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following interventions?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Administering an oral hypoglycemic agent.
- D. Monitoring the patient's blood pressure.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.
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 assessing a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Administering pain medication as needed.
- B. Encouraging deep breathing and coughing exercises.
- C. Monitoring for signs of infection.
- D. Providing wound care and dressing changes.
Correct Answer: B
Rationale: The correct answer is B because deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia after abdominal surgery. By promoting lung expansion and clearing secretions, these exercises enhance oxygenation and prevent respiratory issues. Administering pain medication (A) is important but not the priority. Monitoring for infection (C) and providing wound care (D) are also crucial but come after ensuring respiratory function.
A nurse is caring for a patient with chronic heart failure. Which of the following interventions should the nurse prioritize?
- A. Administering diuretics as prescribed.
- B. Encouraging increased fluid intake.
- C. Restricting sodium intake.
- D. Administering pain medications as needed.
Correct Answer: A
Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.
Which of the following statements reflects a component of spirituality?
- A. It is a belief in the worship of a higher power within an organization.
- B. It involves attendance at a specific church, synagogue, temple, mosque, or house of worship.
- C. It is central to the human experience as a person searches for meaning in life.
- D. It is closely tied to a person's ethnic, social, cultural, and historical background.
Correct Answer: C
Rationale: The correct answer is C because spirituality is a personal and intrinsic search for meaning and purpose in life, which is central to the human experience. This definition aligns with the concept of spirituality as a journey of self-discovery and reflection, independent of organized religion or cultural background.
Explanation for why other choices are incorrect:
A: Worshiping a higher power within an organization implies a religious practice rather than spirituality, which is more individualistic and introspective.
B: Attendance at a specific house of worship is a religious practice, not necessarily reflective of spirituality, which can exist outside formal religious institutions.
D: While spirituality can be influenced by cultural background, it is not solely tied to it, as it transcends social, ethnic, and historical boundaries.