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When examining a patient, the nurse can assess mental health by:
- A. Examining the patient's electroencephalogram.
- B. Observing the patient as he or she performs an IQ test.
- C. Observing the patient and inferring health or dysfunction.
- D. Examining the patient's response to a specific set of questions.
Correct Answer: C
Rationale: The correct answer is C because observing the patient and inferring health or dysfunction allows the nurse to assess mental health holistically. This method considers various factors such as behavior, emotions, communication, and overall functioning. It provides a comprehensive view of the patient's mental well-being.
A: Examining the patient's electroencephalogram is more related to brain activity rather than mental health assessment.
B: Observing the patient as he or she performs an IQ test is limited to cognitive abilities and does not capture the full spectrum of mental health.
D: Examining the patient's response to a specific set of questions may not provide a complete picture of mental health as it focuses on specific aspects rather than overall assessment.
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Which of the following statements represents subjective data about the patient's skin?
- A. Skin dry in appearance
- B. No obvious lesions
- C. Denies colour change
- D. Lesion noted lateral aspect right arm
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following assessments?
- A. Oxygen saturation levels.
- B. Pain levels.
- C. Bowel sounds.
- D. Level of consciousness.
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.
The inspection phase of the physical assessment:
- A. Yields little information
- B. Takes time and reveals a surprising amount of information
- C. Requires a quick glance at the patient's body systems
- D. May be somewhat uncomfortable for the expert practitioner
Correct Answer: B
Rationale: The correct answer is B because the inspection phase of a physical assessment involves visually examining the patient's body, which can reveal a surprising amount of information. This step is crucial in identifying visible abnormalities, such as skin discoloration, swelling, or asymmetry. It helps in assessing the patient's overall appearance, posture, and body movements. This detailed observation can provide valuable insights into the patient's health status and aid in making an accurate diagnosis.
Choice A is incorrect because the inspection phase actually provides significant information. Choice C is incorrect as it downplays the importance of thorough observation. Choice D is incorrect because the discomfort level for the expert practitioner is not a defining factor in the inspection phase.
A nurse is caring for a patient with acute pancreatitis. The nurse should monitor for which of the following signs of complications?
- A. Decreased urine output and increased thirst.
- B. Increased blood pressure and heart rate.
- C. Hypotension and tachycardia.
- D. Tachypnea and cyanosis.
Correct Answer: C
Rationale: The correct answer is C: Hypotension and tachycardia. In acute pancreatitis, complications like hypovolemic shock can lead to hypotension and tachycardia due to fluid shifts and inflammation. Decreased urine output and increased thirst (A) may indicate dehydration but are not specific to pancreatitis. Increased blood pressure and heart rate (B) are not typical signs of complications in pancreatitis. Tachypnea and cyanosis (D) suggest respiratory distress, which is not a common complication of pancreatitis.
A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 4.5 kg (10 lb) in the past month. Which of the following is the nurse's best response in this situation?
- A. Do you own any lethal weapon?
- B. How do other people treat you?
- C. Are you feeling so hopeless that you feel like hurting yourself now?
- D. People often feel hopeless, but the feeling resolves within a few weeks.
Correct Answer: C
Rationale: The correct answer is C: "Are you feeling so hopeless that you feel like hurting yourself now?" This response directly addresses the patient's suicidal ideation and assesses the immediate risk of harm. It shows the nurse's concern for the patient's safety and allows for further evaluation and intervention if necessary.
Option A is incorrect because asking about owning a lethal weapon does not directly address the patient's current mental state and immediate risk of harm. Option B is incorrect as it focuses on external factors rather than the patient's internal feelings of hopelessness and suicidal thoughts. Option D is incorrect as it minimizes the seriousness of the patient's symptoms and may lead to overlooking the urgency of the situation.