Nokea
When listening to a patient's breath sounds, the nurse is unsure about a sound that is hearThe nurse should:
- A. notify the patient's physician immediately.
- B. document the sound exactly as it was heard.
- C. validate the data by asking a colleague to listen to the breath sounds.
- D. assess again in 20 minutes to note whether the sound is still present.
Correct Answer: C
Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.
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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 food should a client with hypercholesterolemia decrease in their diet?
- A. broiled catfish
- B. hamburgers
- C. wheat bread
- D. fresh apples
Correct Answer: B
Rationale: The correct answer is B: hamburgers. Clients with hypercholesterolemia should decrease their intake of foods high in saturated fats, like hamburgers. Saturated fats can raise LDL cholesterol levels. Broiled catfish (A) is a lean protein option, wheat bread (C) is a good source of fiber, and fresh apples (D) are a healthy fruit choice. Hamburgers (B) typically contain high levels of saturated fats from red meat and processed ingredients, making them a less ideal choice for individuals with high cholesterol.
What should the nurse do first when a client with a history of hypertension presents with severe headache?
- A. Administer pain relief
- B. Monitor vital signs
- C. Monitor ECG
- D. Administer insulin
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief. The nurse should address the client's immediate symptom of severe headache to provide comfort and assess the severity of the condition. Pain relief can help decrease anxiety and prevent complications. Monitoring vital signs (B) is important but treating the symptom should take priority. Monitoring ECG (C) is not necessary for a headache presentation. Administering insulin (D) is not indicated for a client presenting with a severe headache.
A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to enjoy doing.' He also says that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, which of the following questions should the nurse ask him?
- A. Has there been any change in your weight?
- B. Are you having any thoughts of suicide?
- C. How long have you been feeling this way?
- D. Are you having feelings of worthlessness?
Correct Answer: C
Rationale: Rationale: The correct answer is C: "How long have you been feeling this way?" This question is essential to differentiate between dysthymic disorder and major depressive disorder. In dysthymic disorder, symptoms persist for at least 2 years, whereas in major depressive disorder, symptoms typically last for at least 2 weeks. By asking how long the patient has been feeling this way, the nurse can determine the duration of the symptoms and make a more accurate diagnosis.
Summary of other choices:
A: "Has there been any change in your weight?" This question is more relevant to assessing changes in appetite, which can be a symptom of depression, but it does not differentiate between dysthymic and major depressive disorders.
B: "Are you having any thoughts of suicide?" While important to assess for safety, this question does not help differentiate between the two disorders.
D: "Are you having feelings of worthlessness?" This question is relevant to assessing symptoms of depression but does not
A nurse is caring for a patient who is undergoing treatment for cancer. Which of the following symptoms would most likely indicate the need for palliative care?
- A. Severe pain and nausea.
- B. Uncontrolled symptoms despite treatment.
- C. Psychosocial support needs.
- D. All of the above.
Correct Answer: D
Rationale: The correct answer is D because palliative care aims to improve the quality of life for patients with serious illnesses like cancer. Severe pain and nausea (A) are common symptoms that palliative care helps manage. Uncontrolled symptoms despite treatment (B) indicate the need for specialized palliative care interventions. Psychosocial support needs (C) are also addressed in palliative care to address emotional and social aspects of the patient's well-being. Therefore, all of the above (D) are indicative of the need for palliative care as it focuses on holistic symptom management and support for the patient.