Nokea
What is the highest priority for a nurse treating a client with a stab wound to the chest?
- A. Secure the airway
- B. Administer oxygen
- C. Turn the mother
- D. Apply an abdominal binder
Correct Answer: A
Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.
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Which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
- A. "It is a sharp, burning pain in my stomach."
- B. "I also have the sweats and nausea when I feel this pain."
- C. "I think this pain is telling me that something is wrong with me."
- D. "This pain happens every time I sit down to use the computer."
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
A nurse is teaching a patient about managing diabetes. Which of the following actions would the nurse emphasize as most important in preventing complications from diabetes?
- A. Monitoring blood glucose levels regularly.
- B. Limiting physical activity to prevent injury.
- C. Maintaining a low-fat, high-protein diet.
- D. Taking insulin as prescribed regardless of blood sugar levels.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment.
2. It helps in preventing hypoglycemia or hyperglycemia complications.
3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels.
4. Empowers the patient to make informed decisions regarding their diabetes management.
Summary of why the other choices are incorrect:
B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity.
C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively.
D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.
A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to enjoy doing.' He also says that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, which of the following questions should the nurse ask him?
- A. Has there been any change in your weight?
- B. Are you having any thoughts of suicide?
- C. How long have you been feeling this way?
- D. Are you having feelings of worthlessness?
Correct Answer: C
Rationale: Rationale: The correct answer is C: "How long have you been feeling this way?" This question is essential to differentiate between dysthymic disorder and major depressive disorder. In dysthymic disorder, symptoms persist for at least 2 years, whereas in major depressive disorder, symptoms typically last for at least 2 weeks. By asking how long the patient has been feeling this way, the nurse can determine the duration of the symptoms and make a more accurate diagnosis.
Summary of other choices:
A: "Has there been any change in your weight?" This question is more relevant to assessing changes in appetite, which can be a symptom of depression, but it does not differentiate between dysthymic and major depressive disorders.
B: "Are you having any thoughts of suicide?" While important to assess for safety, this question does not help differentiate between the two disorders.
D: "Are you having feelings of worthlessness?" This question is relevant to assessing symptoms of depression but does not
The nurse is assessing a teenage girl newly admitted to the pediatric unit. What efficient framework provides additional modesty?
- A. Body systems
- B. Functional
- C. Focused
- D. Head to toe
Correct Answer: D
Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy.
A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach.
B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health.
C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.