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What should the nurse do while dealing with older adults who lose the ability to hear at high-pitched ranges?
- A. Lower the voice pitch.
- B. Insert a stethoscope in the client’s ears.
- C. Use a magic slate or chalkboard.
- D. Ensure that the hearing aid is in good working order.
Correct Answer: A
Rationale: Lowering the voice pitch accommodates age-related hearing loss, improving communication clarity.
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Why would T3, T4, blood chemistry panel, and drug screen tests be performed prior to admission?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.
A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:
- A. excoriation.
- B. dehiscence.
- C. decortication.
- D. evisceration.
Correct Answer: D
Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.
Patients returning from the operating room (OR) should be monitored for atelectasis. Why is this important?
- A. Immobility, anesthesia, and lack of deep breathing place the patient at risk for collapsed lung.
- B. All postoperative patients are at risk for infection.
- C. Postoperative patients might have received too much oxygen during surgery.
- D. Postoperative patients do not receive enough oxygen during surgery.
Correct Answer: A
Rationale: Anesthesia and immobility can lead to atelectasis, where parts of the lung collapse.
When assessing the patient, you notice that there is contraction of his facial muscle after tapping the facial nerve anterior to his ear. This is a sign of
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hypomagnesemia.
- D. Hypocalcemia.
Correct Answer: D
Rationale: Facial twitching upon tapping the facial nerve is a sign of hypocalcemia.