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What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: The correct answer is A. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process.
B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully.
C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood.
D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
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A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. In a nursing health history, the nurse focuses on understanding the patient's expectations, needs, and preferences to provide patient-centered care. This step is essential for building rapport, establishing trust, and tailoring care plans to meet the patient's individual needs.
Incorrect choices:
A: Nurse’s concerns - This is not the primary focus during a nursing health history. The nurse should prioritize understanding the patient's perspective.
C: Current treatment orders - While important, this is typically addressed during the assessment phase, not specifically in the nursing health history.
D: Nurse’s goals for the patient - The nurse's goals should align with the patient's goals, making understanding the patient's expectations crucial.
Which of the ff is the characteristic of a ketogenic diet that is suggested for children with seizures?
- A. High carbohydrate diet
- B. High fat diet
- C. High protein diet
- D. Low fat diet
Correct Answer: B
Rationale: Correct Answer: B (High fat diet)
Rationale:
1. Ketogenic diet for seizures aims to produce ketones for brain energy, achieved through high fat intake.
2. High fat intake helps induce ketosis, which may help reduce seizures in some children.
Incorrect Choices:
A: High carbohydrate diet - Contradicts the purpose of a ketogenic diet.
C: High protein diet - Excessive protein can hinder ketosis and is not the primary focus of a ketogenic diet.
D: Low fat diet - Opposite of the high fat requirement for a ketogenic diet to induce ketosis.
A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?
- A. Anemia and fatigue
- B. A noticeable lump in the neck
- C. Crackles and stridor
- D. Dysphagia or hoarseness
Correct Answer: D
Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.
When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
- A. moist gurgling respirations
- B. Distended neck veins
- C. Weak, slow pulse
- D. Dyspnea and coughing
Correct Answer: C
Rationale: The correct answer is C: Weak, slow pulse. Circulatory overload typically presents with signs of fluid volume excess, such as moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse is not a characteristic sign of circulatory overload, as the heart rate may actually be elevated due to the increased fluid volume. Therefore, a weak, slow pulse would not be likely to occur in this scenario.
A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?
- A. Abdominal pain
- B. Serous drainage from the incision
- C. Hypoactive bowel sounds
- D. Shallow breathing and increasing lethargy
Correct Answer: D
Rationale: The correct answer is D: Shallow breathing and increasing lethargy. This finding could indicate a potential respiratory complication such as atelectasis or pneumonia, which are common postoperative complications. Shallow breathing can lead to inadequate oxygenation and ventilation, causing lethargy due to decreased oxygen delivery to tissues. It is crucial to assess and address respiratory issues promptly to prevent further complications.
A: Abdominal pain is expected postoperatively and can be managed with pain medications.
B: Serous drainage from the incision is a normal finding after surgery and indicates the wound is healing properly.
C: Hypoactive bowel sounds are common after surgery due to decreased peristalsis and can be managed with interventions such as early ambulation and medications.