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When a patient has pneumothorax, the nurse's assessment findings will likely reveal _______. I. absent breadth sounds on the affected side II. Decreased chest expansion unilaterally III. Sharp chest pain IV. Burning chest pain
- A. I, II, III
- B. I, II, IV
- C. III & IV
- D. I & II
Correct Answer: A
Rationale: Pneumothorax is a condition characterized by the presence of air in the pleural space surrounding the lungs, which can lead to lung collapse. The nurse's assessment findings in a patient with pneumothorax are typically as follows:
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Ella's feeling of joining lory in heaven is a manifestation of:
- A. Suicidal intent
- B. Paranoia
- C. Suicidal threat
- D. Suicidal ideation
Correct Answer: D
Rationale: Ella's feeling of joining Lory in heaven is best categorized as suicidal ideation. Suicidal ideation refers to thoughts or fantasies about dying, including thoughts of one's own death or thoughts of wanting to harm oneself. In this scenario, Ella is not explicitly expressing any immediate intent to harm herself or others, nor is she exhibiting paranoia or making a direct threat. Instead, her mention of joining Lory in heaven suggests that she is contemplating the idea of death, which falls under the category of suicidal ideation. It is essential to take such thoughts seriously and seek appropriate help and support for the individual experiencing them.
A nurse involves well-being in her definition of health. What will the primary concern or focus of the nurse when she provides care to a family confronting the imminent death of a family member?
- A. Reinforcing the need for the whole family to adapt to the impending death.
- B. Sharing the nurse's knowledge on the client's symptoms of grief
- C. Discussing the perceived meaning of life with the family
- D. Administering pain medication so that the client can be kept comfortable
Correct Answer: A
Rationale: When a nurse involves well-being in her definition of health, it indicates a holistic approach that considers not only physical health but also emotional, mental, and social aspects of well-being. In the context of a family confronting the imminent death of a family member, the primary concern of the nurse would be to focus on reinforcing the need for the whole family to adapt to the impending death. This involves providing emotional support, facilitating communication, addressing coping mechanisms, and assisting the family in coming to terms with the situation. By emphasizing the importance of the whole family adapting to the imminent death, the nurse can help promote holistic well-being for the family during this challenging time.
The nurse assists a health care provider in performing a liver biopsy. After the biopsy, the nurse should place the client in which position?
- A. Prone
- B. Supine
- C. A left side-lying position with a small pillow or folded towel under the puncture site
- D. A right side-lying position with a small pillow or folded towel under the puncture site
Correct Answer: C
Rationale: Placing the client in a left side-lying position after a liver biopsy helps to promote pressure on the puncture site, which can reduce the risk of bleeding. Placing a small pillow or folded towel under the puncture site provides additional support and helps to maintain pressure on the area. This position also helps prevent the client from putting pressure on the abdomen, which could potentially affect the biopsy site and increase the risk of bleeding or complications. Overall, positioning the client on the left side with support under the puncture site is the most appropriate and safest option after a liver biopsy.
The nurse develops the following hypothesis: Elderly women receive less aggressive treatment for terminally-ill spine patients than younger women. Which variable would be considered to be the independent variable?
- A. Degree of treatment received
- B. Age of the patient
- C. Use of inpatient treatment
- D. Type of complications being treated
Correct Answer: B
Rationale: The independent variable in an experiment is the variable that is manipulated or determined by the researcher. In this hypothesis, the nurse is suggesting that the age of the patient (elderly vs. younger) influences the aggressiveness of treatment received. Therefore, the age of the patient is the independent variable in this scenario. The dependent variable would be the degree of treatment received, as it is expected to be influenced by the independent variable, which is the age of the patient.
Which type of plan should the nurse employ to assess the strengths and weaknesses of the organization?
- A. Nursing care
- B. Strategic
- C. Operational
- D. Program
Correct Answer: B
Rationale: To assess the strengths and weaknesses of the organization, the nurse should employ a strategic plan. A strategic plan involves setting overall goals, objectives, and strategies for the organization. It provides a comprehensive framework for evaluating the current state of the organization, identifying areas of improvement, and aligning resources to achieve long-term success. By using a strategic plan, the nurse can conduct a thorough analysis of the organization's internal and external factors, including its strengths and weaknesses, to determine the most effective course of action for the future.