Nokea
When teaching a preoperative older patient, which of the following is a technique to improve learning?
- A. Sit in front of window in bright sunlight.
- B. Speak in high tone.
- C. Use small, white-on-black printed
- D. Eliminate background noise. materials.
Correct Answer: D
Rationale: The correct answer is D, "Eliminate background noise." This technique is essential for older patients as they may have age-related hearing impairments. By reducing background noise, the patient can better focus on the information being conveyed. Sitting in bright sunlight (A) may cause glare and make it difficult to read or see clearly. Speaking in a high tone (B) may be perceived as aggressive or patronizing. Using small, white-on-black printed materials (C) may be challenging for older patients with visual impairments. Thus, eliminating background noise is the most effective technique to improve learning in preoperative older patients.
You may also like to solve these questions
The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?
- A. Clarify discrepancies of assessment data with the client.
- B. Validate client data with members of the health care team.
- C. Document all data collected in the nursing history and physical examination.
- D. Seek input from family members regarding the client’s breathing at home.
Correct Answer: A
Rationale: Step-by-step rationale:
1. The nurse should clarify discrepancies of assessment data with the client to ensure accurate information.
2. The client's denial of breathing problems conflicts with physical signs, indicating a potential lack of awareness or reluctance to disclose symptoms.
3. By clarifying with the client, the nurse can address any misunderstandings or encourage honest communication.
4. This approach promotes client-centered care and ensures a comprehensive understanding of the client's health status.
Summary:
- Choice A is correct as it addresses the need to clarify discrepancies with the client for accurate assessment.
- Choice B is incorrect as validation with the healthcare team may not provide insight into the client's perception.
- Choice C is incorrect as it does not address the need to resolve conflicting assessment data.
- Choice D is incorrect as family input may not provide accurate information if the client denies symptoms.
A client was brought to the emergency room with complains of difficulty of breathing. What can lead the nurse to suspect that the client is experiencing acute respiratory distress syndrome (ARDS)?
- A. paO2 of 95, pCO2 of 43, x-ray showing enlarged heart, bradycardia
- B. Thick green sputum production, paO2 of 74, pH of 7.41
- C. restlessness, suprasternal retractions, paO2 of 62
- D. wheezes, slow, deep respirations, pCO2 of 52, pH of 7.35
Correct Answer: C
Rationale: Step-by-step rationale for choice C being correct:
1. Restlessness: Indicates increased work of breathing and hypoxia.
2. Suprasternal retractions: Sign of respiratory distress.
3. paO2 of 62: Indicates severe hypoxemia, common in ARDS.
Summary:
A: Enlarged heart on x-ray does not directly indicate ARDS.
B: Thick green sputum suggests infection, not specific to ARDS.
D: Wheezes and slow respirations are not typical of ARDS, and pCO2 is normal in ARDS.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: The correct answer is A: Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. This is because regular screening with both tests can help detect prostate cancer early. The digital rectal exam allows the doctor to feel for any abnormalities in the prostate gland, while the PSA test measures the levels of a specific protein produced by the prostate gland. If there are any concerning findings, further diagnostic tests can be done to confirm prostate cancer.
Choice B is incorrect because transrectal ultrasound is not a recommended screening test for prostate cancer. Choice C is incorrect as testicular self-examinations are for detecting testicular cancer, not prostate cancer. Choice D is incorrect as CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.
During the evaluation phase, what key action does the nurse perform?
- A. Diagnose the client’s condition based on new information.
- B. Identify nursing interventions for client care.
- C. Determine the effectiveness of the care plan.
- D. Develop goals and outcomes for client care.
Correct Answer: C
Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately.
Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.