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When a nurse is performing a neurological assessment, which of the following is most important to assess first?
- A. Patient's reflexes
- B. Patient's cranial nerve function
- C. Patient's level of consciousness
- D. Patient's pupil response
Correct Answer: C
Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.
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Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
- A. Head elevated to 45 degrees
- B. Have the patient lie flat
- C. Place the patient in the supine position
- D. Position the patient on their side
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for signs of which of the following complications?
- A. Jaundice.
- B. Hypoglycemia.
- C. Hyperglycemia.
- D. Anemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease.
B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely.
C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication.
D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.
Which of the following statements illustrates the biomedical model of Western traditional views?
- A. Health is viewed as the absence of disease.
- B. Optimal health is viewed as high-level wellness.
- C. Health and disease are considered parts of a cyclical process.
- D. The treatment of disease is nursing's primary focus.
Correct Answer: A
Rationale: The correct answer is A because the biomedical model focuses on defining health as the absence of disease. This model emphasizes biological factors in understanding and treating illnesses. It is reductionist in nature, viewing health issues as purely physical and separate from social or psychological aspects. Choices B, C, and D do not align with the biomedical model. B emphasizes overall well-being, not just the absence of disease. C suggests a more holistic approach, while D implies a focus on nursing rather than the medical model's emphasis on disease treatment.
A nurse is providing discharge instructions to a patient who had a stroke. Which of the following statements by the patient indicates the need for further education?
- A. I will take my medications as prescribed.
- B. I will follow up with my doctor regularly.
- C. I can resume driving after a few weeks of rest.
- D. I will report any sudden changes in my vision or speech.
Correct Answer: C
Rationale: The correct answer is C. After a stroke, patients need to be evaluated by a healthcare professional before resuming driving. This is crucial to ensure the safety of the patient and others on the road. Choice A shows medication compliance, B demonstrates follow-up care, and D emphasizes monitoring symptoms, all of which are essential post-stroke. However, choice C indicates a lack of understanding about the importance of medical clearance before driving, hence the need for further education.
A patient tells the nurse that he is allergic to penicillin. Which of the following would be the nurse's best response to this information?
- A. "Are you allergic to any other drugs?"
- B. "How often have you received penicillin?"
- C. "I'll record your allergy information on your chart, so you won't receive any."
- D. "Please describe what happens to you when you take penicillin."
Correct Answer: D
Rationale: The correct answer is D: "Please describe what happens to you when you take penicillin." This response allows the nurse to gather detailed information about the patient's allergic reaction to penicillin, which is crucial for assessing the severity of the allergy and determining appropriate treatment options. By understanding the specific symptoms experienced by the patient, the nurse can help prevent potential adverse reactions in the future.
Choices A, B, and C are incorrect because:
A: This question does not address the immediate concern of the patient's penicillin allergy and does not help in understanding the nature of the allergic reaction.
B: The frequency of penicillin usage is not as relevant as understanding the nature and severity of the allergic reaction.
C: While recording allergy information is important, it does not address the need for understanding the patient's specific allergic response to penicillin.