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When determining hearing acuity, if the client reports first perceiving sound at ___ dB, then his or her hearing is normal.
- A. 4
- B. 8
- C. 12
- D. 16
Correct Answer: A
Rationale: Normal hearing acuity is typically defined as perceiving sound at 0-25 dB. Therefore, 4 dB would be within the range of normal hearing.
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In a Hispanic patient who claims to have empacho, what assessment findings would the nurse expect?
- A. Abdominal pain and cramping
- B. Anxiety,insomnia anorexia and social isolation
- C. Nightmares weakness and a sense of suffocation
- D. Headaches,stomach problems and loss of consciousness
Correct Answer: A
Rationale: Empacho is a folk illness commonly reported among Hispanic populations, characterized by abdominal pain and cramping due to perceived blockage in the digestive system.
When working with older patients who identify with a specific ethnic group, the nurse recognizes that health care problems may occur in these patients because they
- A. Live with extended families who isolate the patient.
- B. Live in rural areas where services are not readily available.
- C. Eat ethnic foods that do not provide all essential nutrients.
- D. Have less income to spend for medications and health care services.
Correct Answer: D
Rationale: Limited financial resources hinder access to necessary healthcare services, making it difficult for older adults to afford medications and treatments.
A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
- A. I will reduce my sodium intake to help control my blood pressure.
- B. I need to start walking at least 30 minutes most days of the week.
- C. I can continue drinking alcohol as long as it is not in excess.
- D. I will check my blood pressure regularly at home.
Correct Answer: C
Rationale: The correct answer is C because excessive alcohol consumption can raise blood pressure. Step 1: Alcohol can lead to hypertension. Step 2: Limiting alcohol intake is crucial in managing hypertension. Step 3: Choices A, B, and D promote healthy behaviors that help control blood pressure. Summary: Choice C is incorrect as it goes against hypertension management, while choices A, B, and D align with lifestyle modifications for hypertension.
What behavioral clues will you watch for to identify an increased risk for suicide?
- 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 presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
- A. 1530 (3:30 PM)
- B. 1600 (4:00 PM)
- C. 1630 (4:30 PM)
- D. 1700 (5:00 PM)
Correct Answer: C
Rationale: The correct answer is C: 1630 (4:30 PM). The rationale is as follows:
1. The standard guideline for performing percutaneous coronary intervention (PCI) in acute MI is within 90 minutes of arrival at the hospital.
2. The client arrived at 1500 (3:00 PM), so adding 90 minutes to this time gives us 1630 (4:30 PM).
3. This timing aligns with The Joint Commission's Core Measures for timely PCI in acute MI cases.
4. Therefore, the correct time for the client to have PCI performed is 1630 (4:30 PM).
In summary, choices A, B, and D are incorrect because they do not align with the 90-minute guideline for performing PCI in acute MI cases, as mandated by The Joint Commission's Core Measures.