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When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?
- A. Identifying existing levels of wellness
- B. Evaluating previous problems and goals
- C. Identifying potential problems the individual may develop
- D. Focusing on strengths and reflecting an individual's transition to higher levels of wellness
Correct Answer: C
Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.
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The nurse is planning health education for a 65-year-old woman who has had a cerebrovascular accident (stroke) and is aphasic. Which of the following is most important to use when assessing mental health in this situation?
- A. Please count back from 100 by sevens.
- B. I will name three items and ask you to repeat them in a few minutes.
- C. Please point to articles in the room and parts of the body as I name them.
- D. What would you do if you found a stamped, addressed envelope on the sidewalk?
Correct Answer: C
Rationale: The correct answer is C: Please point to articles in the room and parts of the body as I name them. This is the most important assessment for mental health in an aphasic patient post-stroke because it evaluates their comprehension, communication abilities, and cognitive function. Pointing to articles and body parts demonstrates understanding and ability to follow instructions, which are crucial aspects of mental health assessment in this context.
A: Please count back from 100 by sevens - This choice involves memory and mathematical abilities, which may not accurately assess mental health in an aphasic patient.
B: I will name three items and ask you to repeat them in a few minutes - This choice tests memory recall, which is not as relevant for assessing mental health in an aphasic patient post-stroke.
D: What would you do if you found a stamped, addressed envelope on the sidewalk? - This choice assesses problem-solving skills, which may not be the most appropriate indicator of mental health in an aphasic patient.
Why is the concept of prevention essential in describing health?
- A. Disease can be prevented by treating the external environment.
- B. Most deaths among Canadians under age 65 are not preventable.
- C. Prevention places emphasis on the link between health and personal behaviour.
- D. The means to prevention is through treatment provided by primary health care practitioners.
Correct Answer: C
Rationale: The correct answer is C because prevention emphasizes the importance of personal behavior in maintaining health. It highlights the role of individual choices in preventing diseases and promoting well-being. A is incorrect because prevention focuses on proactive measures rather than treating external factors. B is incorrect as it contradicts the importance of prevention in reducing preventable deaths. D is incorrect because prevention is about avoiding health issues before they occur, not treating them after they have developed.
A patient tells the nurse that she believes in "the hot"“cold theory, where illness is caused by hot or cold entering the body." Which of the following responses from the nurse would be most appropriate?
- A. I do not believe in this theory, but tell me about it.
- B. I know that this is your belief, but the cause is actually a virus.
- C. I did not take this in school, so it's unfamiliar to me.
- D. I have not heard of this theory. Tell me more.
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for which of the following complications?
- A. Jaundice.
- B. Anemia.
- C. Hyperglycemia.
- D. Hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, the liver is unable to properly process bilirubin, leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. It is a common complication of liver disease and indicates impaired liver function. Anemia (choice B) may occur in liver disease, but it is not the primary complication. Hyperglycemia (choice C) and hypoglycemia (choice D) are more commonly associated with diabetes or pancreatic disorders, rather than chronic liver disease. Therefore, monitoring for jaundice is crucial in the care of a patient with chronic liver disease.
A pregnant woman states, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?
- A. It was a nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman's fears.
- B. It was a therapeutic response. The nurse should have shared her own experience with the patient to make her feel better.
- C. It was a nontherapeutic response. The nurse is essentially giving the message to the woman that labour cannot be tolerated without medication.
- D. It was a therapeutic response. By providing false assurance, the nurse created a sense of security and opened the door for more discussion.
Correct Answer: B
Rationale: The correct answer is B because the nurse's response was therapeutic by sharing her own experience to empathize with the patient. This helps establish a connection and validate the patient's feelings. It shows understanding without dismissing the patient's concerns.
A is incorrect because the nurse did not provide false reassurance but offered a comforting perspective.
C is incorrect as the nurse did not imply that medication was necessary but rather highlighted its availability as an option.
D is incorrect since the response did not provide false assurance but rather shared personal experience to offer support.