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When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which of the following statements about this situation is true?
- A. The nurse should focus on the patient's verbal message and try to ignore the nonverbal behaviors.
- B. The nurse should ask someone who knows the patient well to help interpret this discrepancy.
- C. The nurse should try to integrate the verbal and nonverbal messages and then interpret them as an 'average.'
- D. The nurse should focus on the patient's nonverbal behaviors because these are often more reflective of a patient's true feelings.
Correct Answer: B
Rationale: The correct answer is B because asking someone who knows the patient well can provide valuable insight into the meaning behind the verbal and nonverbal communication discrepancy. This helps in understanding the context and potential reasons for the inconsistency. Option A is incorrect as ignoring nonverbal behaviors can lead to missing important cues. Option C of interpreting messages as an 'average' may oversimplify the complexity of communication. Option D is incorrect as while nonverbal behaviors can provide valuable information, solely focusing on them may not give a complete understanding of the situation.
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Which intervention should the nurse implement for a client who is experiencing a seizure?
- A. Place the client on their side and protect their head
- B. Loosen the client's clothing and ensure safety
- C. Monitor the client's airway and give oxygen
- D. Administer antiepileptic medications
Correct Answer: D
Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.
A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following lab results would the nurse expect to be elevated in this patient?
- A. Blood urea nitrogen (BUN).
- B. Calcium.
- C. Potassium.
- D. Sodium.
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.
A patient with chronic kidney disease (CKD) is being assessed. The nurse would expect to find which of the following symptoms?
- A. Weight loss and polyphagia.
- B. Edema and proteinuria.
- C. Hypertension and tachycardia.
- D. Hypothermia and bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Edema and proteinuria. In CKD, the kidneys are unable to filter waste products effectively, leading to fluid retention (edema) and protein leaking into the urine (proteinuria). Edema occurs due to fluid buildup from decreased kidney function. Proteinuria is a result of damaged glomeruli in the kidneys, allowing proteins to leak into the urine. Weight loss and polyphagia (excessive hunger) are not typical symptoms of CKD. Hypertension and tachycardia can occur in CKD due to fluid overload and electrolyte imbalances. Hypothermia and bradycardia are not common symptoms of CKD and would be more indicative of other conditions.
A 59-year-old patient tells the nurse that he is in the clinic to "check up on his ulcerative colitis." He has been having "black stools" in the last 24 hours. How would the nurse document his reason for seeking care?
- A. J.M. is a 59-year-old male here for "ulcerative colitis."
- B. J.M. came into the clinic complaining of black stools in the past 24 hours.
- C. J.M., a 59-year-old male, states he has ulcerative colitis and wants to have it checked up.
- D. J.M. is a 59-year-old male here for having "black stools" in the past 24 hours.
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the patient's chief complaint of having black stools in the last 24 hours, which is a concerning symptom suggestive of gastrointestinal bleeding. This documentation is specific and focused on the reason for seeking care, prioritizing the urgent nature of the symptom.
Choice A is incorrect because it does not mention the presenting symptom of black stools. Choice B is incorrect as it does not directly state the reason for seeking care. Choice C is incorrect as it focuses on the patient's self-diagnosis of ulcerative colitis rather than the current concerning symptom of black stools.
A woman is describing the problems she is having with her 2-year-old son. "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." The nurse's best verbal response would be:
- A. Go on, I'm listening.
- B. Fits? Tell me what you mean by this.
- C. Yes, it can be upsetting when a child has a fit.
- D. Don't be upset when he has a fit; every 2-year-old has fits.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively.
Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.