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When communicating with a patient who speaks a different language, what is the nurse's best approach?
- A. Use a family member or friend as an interpreter to convey information.
- B. Rely solely on written instructions to avoid language barriers.
- C. Utilize professional medical interpreters to ensure accurate communication.
- D. Speak loudly and slowly to ensure the patient understands.
Correct Answer: C
Rationale: Using professional medical interpreters is the best approach when communicating with a patient who speaks a different language. This ensures accurate communication and helps prevent misunderstandings that can have serious consequences for the patient's health. Family members or friends may not be fluent in the necessary medical terminology and could unintentionally misinterpret information. Relying solely on written instructions can also be risky as the patient may have difficulty reading or comprehending the information. Speaking loudly and slowly may come across as disrespectful and does not address the root issue of the language barrier. Professional medical interpreters are trained to facilitate effective communication between healthcare providers and patients, ensuring that the patient receives the best possible care.
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A patient presents with recurrent episodes of sudden, severe vertigo lasting hours, accompanied by nausea, vomiting, and nystagmus. Vestibular function tests demonstrate unilateral weakness. Which of the following conditions is most likely responsible for this presentation?
- A. Vestibular neuritis
- B. Benign paroxysmal positional vertigo (BPPV)
- C. Ménière's disease
- D. Acoustic neuroma
Correct Answer: A
Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours, along with nausea, vomiting, nystagmus, and unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is an inflammatory disorder of the vestibular nerve, typically viral in origin, leading to acute onset of vertigo. Patients often experience severe vertigo, imbalance, nausea, and vomiting, along with characteristic nystagmus. Unilateral weakness on vestibular function testing supports the diagnosis of vestibular neuritis, as it indicates dysfunction of one vestibular organ. Benign paroxysmal positional vertigo (BPPV) typically presents with brief episodes of vertigo triggered by changes in head position without associated unilateral vestibular weakness. Ménière's disease is characterized by recurrent episodes of vertigo associated with fluctuating hearing loss, tinnitus, and aural fullness, and
Which of the following charting rules will keep the nurse legally safe? I. Documenting worries and all concerns as verbalized by the patient. II Charting at the end of the shift only. III.Discussing of recorded cases and diagnosis of the patient. IV. Recording all information verbalized by patient and family.
- A. III, IV
- B. I
- C. I, III
- D. II
Correct Answer: B
Rationale: The correct charting rule to keep the nurse legally safe is to document worries and all concerns as verbalized by the patient (Choice I). This is important for accurately reflecting the patient's condition, communication, and potential interventions. Charting at the end of the shift only (Choice II) is not recommended as it can lead to missed important details or delayed documentation. Discussing recorded cases and diagnoses of the patient (Choice III) breaches patient confidentiality and violates HIPAA laws. Recording all information verbalized by the patient and family (Choice IV) may include unnecessary details and could potentially lead to misinterpretation or misunderstanding, which might not be legally advantageous.
A patient presents with a painless, gradually enlarging mass in the left neck, anterior to the sternocleidomastoid muscle. Fine-needle aspiration cytology reveals thyroid follicular cells. Which of the following conditions is most likely responsible for this presentation?
- A. Thyroglossal duct cyst
- B. Lymphadenopathy
- C. Thyroid adenoma
- D. Thyroid carcinoma
Correct Answer: C
Rationale: The presentation described is most consistent with a thyroid adenoma. Thyroid adenomas are benign neoplasms of the thyroid gland and can present as painless, gradually enlarging masses in the neck. Fine-needle aspiration cytology revealing thyroid follicular cells further supports the diagnosis of a thyroid adenoma. Thyroglossal duct cysts typically present as midline neck masses that move with swallowing, while lymphadenopathy presents as enlarged lymph nodes and may be associated with infection or malignancy. Thyroid carcinoma may also present as a neck mass but is more likely to be associated with other features such as vocal cord paralysis, hoarseness, or enlarged cervical lymph nodes.
Nurse Cris received information from some community residents who suspect that a neighbor ls abusing his young child. Which should be the PRIORITY nursing action ?
- A. Report the police authorities.
- B. Notify the social worker.
- C. Ignore the information
- D. Validate the information
Correct Answer: A
Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.
A postpartum client exhibits signs of postpartum psychosis, including hallucinations, delusions, and disorganized behavior. Which nursing intervention is most appropriate?
- A. Administering antipsychotic medication as ordered
- B. Encouraging the client to participate in group therapy sessions
- C. Providing education on coping skills and stress management
- D. Notifying the healthcare provider immediately
Correct Answer: D
Rationale: When a postpartum client exhibits signs of postpartum psychosis such as hallucinations, delusions, and disorganized behavior, it is crucial to involve the healthcare provider immediately. Postpartum psychosis is a psychiatric emergency that requires prompt assessment and intervention by mental health professionals. The healthcare provider can determine the appropriate course of action, which may include hospitalization, medication management, and specialized psychiatric care. Delaying notification can lead to serious consequences for both the client and her infant, so timely intervention is essential in managing postpartum psychosis.