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When interviewing a patient, it is important for the nurse to obtain some basic history. Which of the following statements should be explored more fully during an interview? The patient states that he:
- A. Sleeps like a baby.
- B. Has no health problems.
- C. Never did too good in school.
- D. Is currently not taking any medication.
Correct Answer: C
Rationale: The correct answer is C: "Never did too good in school." This statement should be explored further during an interview because it can provide insights into the patient's educational background, potential learning difficulties, or past experiences that may impact their health literacy or understanding of medical information. Understanding the patient's educational history can help the nurse tailor communication and education strategies effectively.
A: "Sleeps like a baby" is not as critical for further exploration as it pertains to the patient's sleep quality.
B: "Has no health problems" is important information but does not require immediate further exploration.
D: "Is currently not taking any medication" is important for medication reconciliation but does not warrant immediate further exploration in this context.
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What is the most appropriate intervention for a client with shortness of breath and chest tightness?
- A. Administer bronchodilators
- B. Administer oxygen
- C. Apply a cold compress
- D. Administer IV antibiotics
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.
What does the Health Insurance Portability and Accountability Act (HIPAA) regulate?
- A. Who will provide client care
- B. Privacy of information
- C. How insurance information is obtained
- D. Where a chart can be stored
Correct Answer: B
Rationale: The correct answer is B because HIPAA regulates the privacy and security of protected health information. This includes how healthcare providers, insurers, and other entities handle and safeguard patient information to ensure confidentiality. Choice A is incorrect as HIPAA does not dictate who provides client care. Choice C is incorrect as HIPAA focuses on the protection of health information, not how insurance information is obtained. Choice D is incorrect as HIPAA does not specify where a chart can be stored, but rather how the information within it is protected.
A man has been admitted to the observation unit after having been treated for a large cut on his foreheaAs the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, "I quit smoking after my wife died 7 years ago." However, the nurse notices an open packet of cigarettes in his shirt pocket. If using confrontation as a response, the nurse could say:
- A. Mr. K., you have said that you don't smoke, but I see that you have an open packet of cigarettes in your pocket.
- B. Mr. K., come on, tell me how much you smoke.
- C. Mr. K., I didn't realize your wife had dieIt must be difficult for you at this time. Please tell me more about that.
- D. Mr. K., I know that you are lying.
Correct Answer: D
Rationale: The correct answer is D because using confrontation in this situation involves addressing the discrepancy between the patient's statement and observed behavior without being aggressive or judgmental. By stating, "Mr. K., I know that you are lying," the nurse directly addresses the inconsistency, encouraging honesty and open communication. This approach can help build trust and facilitate a more honest discussion about the patient's tobacco use.
Choice A is incorrect as it is too direct and may come across as accusatory. Choice B is also incorrect as it does not acknowledge the discrepancy and may not lead to a productive conversation. Choice C is incorrect as it avoids addressing the issue and focuses on the patient's personal situation instead of the behavior in question.
What is the best intervention for a client who is vomiting after surgery?
- A. Administer antiemetics
- B. Place the client in a supine position
- C. Encourage deep breathing
- D. Administer morphine
Correct Answer: D
Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting.
Other choices are incorrect because:
A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting.
B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure.
C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.
Which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.