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The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
- A. UAP splint the patient's chest during coughing.
- B. UAP assist the patient to ambulate to the bathroom.
- C. UAP help the patient to a bedside chair for meals.
- D. UAP lower the head of the patient's bed to 15 degrees.
Correct Answer: D
Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.
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What action by the nurse is appropriate when examining a 16-year-old male teenager?
- A. Discuss health teaching with the teenager to promote wellness.
- B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
- C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
- D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
Correct Answer: D
Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Document the amount of drainage every eight hours
- B. Obtain samples of drainage for culture from the system
- C. Assess patient pain level associated with the chest tube
- D. Check the water-seal chamber for the correct fluid level
Correct Answer: A
Rationale: The correct answer is to document the amount of drainage every eight hours. UAP education typically includes tasks related to documentation of intake and output. Obtaining samples of drainage for culture and assessing patient pain level are nursing responsibilities that require licensed nursing personnel's education and scope of practice. Checking the water-seal chamber for the correct fluid level also falls under the nursing role, as it involves monitoring and maintaining the chest tube system, which requires nursing knowledge and training.
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when assessing a patient?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: A
Rationale: The correct answer is Palpation. Palpation involves using the sense of touch to assess texture, temperature, moisture, and swelling in a patient. This technique allows the nurse to feel for abnormalities and changes in the patient's tissues. Inspection primarily relies on visual assessment, while percussion involves tapping on the body to produce sounds and assess underlying structures. Auscultation, on the other hand, involves listening to sounds within the body using a stethoscope. Therefore, in the context of assessing texture, temperature, moisture, and swelling, palpation is the most appropriate technique.
While performing the physical examination, why does the nurse share information and briefly teach the patient?
- A. To help the patient feel more comfortable and gain control of the situation
- B. To build rapport and increase the patient's confidence in the examiner
- C. To assist the patient in understanding his or her disease process and treatment modalities
- D. To aid the patient in identifying questions about his or her disease and potential areas of needed education
Correct Answer: B
Rationale: Sharing information and briefly teaching the patient during a physical examination helps build rapport and increase the patient's confidence in the examiner. This approach gives the patient a sense of control in a situation that can often be overwhelming. While sharing information may make the patient feel more comfortable, the primary goal is to enhance the patient's confidence in the examiner. Providing information does not necessarily directly assist the patient in understanding their disease process and treatment modalities, as this may require a more in-depth explanation. The main focus is on establishing a trusting relationship and empowering the patient during the examination, rather than solely aiding in identifying questions or areas needing education.
A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak "perfect English."? What is this woman likely experiencing?
- A. Culture shock
- B. Cultural taboos
- C. Cultural unfamiliarity
- D. Culture disorientation
Correct Answer: A
Rationale: The woman in the scenario is likely experiencing culture shock. Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group due to sudden strangeness, unfamiliarity, and incompatibility with the individual's perceptions and expectations. In this case, the woman's feelings of shyness and retreating due to not feeling confident in speaking 'perfect English' align with symptoms of culture shock. The other choices are incorrect: Cultural taboos refer to behaviors or actions that are prohibited within a particular culture; cultural unfamiliarity suggests a lack of knowledge about a specific culture, which is not the case here; and culture disorientation is not a commonly used term in cultural psychology, making it an incorrect option.