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The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse?
- A. A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away.
- B. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.
- C. A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away.
- D. A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.
Correct Answer: A
Rationale: A person whose vision is measured at 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. In this measurement system, the first number represents how far away the person is from the eye chart (the testing distance), and the second number indicates how far away a person with normal vision can be from the chart to see the same line of letters or objects. Therefore, if someone has 20/40 vision, it means they need to be at 20 feet to see what a person with 20/20 vision can see at 40 feet.
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A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor?
- A. Womens knowledge of how their breasts normally look and feel
- B. The rapport that exists between the woman and her primary care provider
- C. Synchronizing womens routines around BSE with the performance of mammograms
- D. Womens knowledge of the pathophysiology of breast cancer
Correct Answer: A
Rationale: Effective breast self-examination (BSE) relies significantly on women's knowledge of their own breasts. Understanding how their breasts normally look and feel allows women to detect any changes such as lumps, dimpling, or discharge, which may be early signs of breast abnormalities like cancer. By being familiar with their breasts' normal appearance and texture, women can promptly seek medical attention if they notice any unusual changes. This self-awareness and familiarity with their breasts are crucial in enabling women to perform BSE effectively and to detect any potential issues early on.
When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan?
- A. Increasing carbohydrates to 55% to 60% of total intake
- B. Providing vitamin and mineral supplements
- C. Decreasing protein intake to 0.75 g/kg/day
- D. Limiting water before and after exercise
Correct Answer: A
Rationale: When planning care for an adolescent who plays sports, it is important to provide adequate nutrition to meet their increased energy needs. Carbohydrates are the main source of energy, providing fuel for physical activity. Adolescents engaged in sports require a higher carbohydrate intake and should aim for 55% to 60% of their total daily kilocalories to support their activity levels. Carbohydrates are essential for providing energy during exercise, building and repairing muscles, and promoting overall performance. Increasing carbohydrate intake in the diet is a key modification to support the energy demands of an active adolescent involved in sports.
A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an increase in the patients abdominal girth and the patient complains of bloating. What is the nurses most appropriate action?
- A. Provide the patient with an unsweetened, carbonated beverage.
- B. Apply warm compresses to the patients lower abdomen.
- C. Provide an ice pack to apply to the perineum and suprapubic region.
- D. Assist the patient into a prone position.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take in this situation is to apply warm compresses to the patient's lower abdomen. Abdominal bloating and an increase in abdominal girth can be common following a vaginal hysterectomy. Applying warm compresses to the lower abdomen can help to relieve bloating and discomfort by promoting relaxation of the abdominal muscles and increasing blood flow to the area. This can provide relief to the patient and support their recovery process. Applying warm compresses is a non-invasive intervention that can be easily implemented and is commonly used in post-operative care to address abdominal discomfort.
A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment?
- A. Gag reflex
- B. Deep tendon reflexes
- C. Abdominal girth
- D. Hearing acuity
Correct Answer: A
Rationale: The most critical assessment parameter to include in the initial assessment of a patient with a brain tumor scheduled for surgery is the gag reflex. The gag reflex is a protective mechanism that prevents the entry of foreign objects into the airway and lungs. Patients undergoing brain tumor resection may be at risk for impaired gag reflex due to the effects of the tumor on cranial nerves or related structures. Identifying any impairment in the gag reflex is essential to prevent aspiration during and after the surgical procedure. Monitoring the gag reflex allows the healthcare team to take necessary precautions to protect the patient's airway and prevent complications. Therefore, assessing the gag reflex is crucial in the care of a patient with a brain tumor undergoing surgery.
The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?
- A. Would you like me to have the chaplain come speak with you?
- B. Youll learn much about the promise of a cure for HIV.
- C. Can you tell me what concerns you most about dying?
- D. You need to maintain hope because you may live for several years.
Correct Answer: C
Rationale: When the patient expresses fear of dying, the best response from the nurse would be to address the patient's concerns directly by asking, "Can you tell me what concerns you most about dying?" This response shows empathy and allows the patient to express their fears and thoughts openly. By understanding the specific concerns, the nurse can provide appropriate support and guidance to help alleviate the patient's fears and anxieties. It also opens up a dialogue for the nurse to provide information and reassurance based on the patient's individual needs and feelings.