Nokea
When the nurse interacts with patients face-to-face such as in getting information during the assessment phase of the nursing process, the level of communication is which of the following?
- A. Intrapersonal
- B. Public communication
- C. Interpersonal
- D. Verbal
Correct Answer: C
Rationale: When the nurse interacts with patients face-to-face to gather information during the assessment phase of the nursing process, the level of communication is considered interpersonal. Interpersonal communication involves two or more individuals who are connected in a meaningful way. In this scenario, the nurse and the patient are engaging in a personal exchange of information, thoughts, and feelings. This type of communication is essential in building rapport, understanding the patient's needs, and providing effective care. It focuses on creating a supportive and therapeutic relationship between the nurse and the patient, which is crucial for delivering high-quality nursing care.
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After the surgical procedure, the nurse assists with applying the surgical dressing. What is the nurse's priority action?
- A. Documenting the dressing change in the patient's chart
- B. Assessing the surgical incision for signs of complications
- C. Providing instructions to the patient about wound care
- D. Ensuring that the dressing is applied securely and correctly
Correct Answer: B
Rationale: The nurse's priority action after applying the surgical dressing is to assess the surgical incision for signs of complications. This includes checking for any signs of infection, excessive bleeding, or other complications related to the surgical site. Early detection of such complications is crucial for ensuring proper healing and preventing serious complications. Once the assessment is done and any issues are addressed, the nurse can proceed with documenting the dressing change, providing instructions to the patient about wound care, and ensuring that the dressing is securely and correctly applied.
A postpartum client who experienced a perineal laceration reports pain and discomfort during defecation. What nursing intervention should be prioritized to alleviate symptoms?
- A. Recommending the use of stool softeners or laxatives
- B. Encouraging the client to increase fluid and fiber intake
- C. Providing perineal care using peri-bottles with warm water
- D. Instructing the client on proper positioning for defecation
Correct Answer: A
Rationale: The priority nursing intervention for a postpartum client who experienced a perineal laceration and reports pain and discomfort during defecation is to recommend the use of stool softeners or laxatives. Perineal lacerations can lead to pain and discomfort during bowel movements due to the strain that passing stools may cause on the tender area. Stool softeners or laxatives can help soften the stool, making it easier and less painful for the client to have bowel movements. It is important to alleviate the discomfort and promote bowel regularity to prevent complications such as constipation, which can further exacerbate the pain and delay healing of the perineal laceration.
Which of the following structures is responsible for producing hydrochloric acid and intrinsic factor, essential for the digestion of proteins and absorption of vitamin B12, respectively?
- A. Liver
- B. Stomach
- C. Pancreas
- D. Small intestine
Correct Answer: B
Rationale: The stomach is responsible for producing hydrochloric acid and intrinsic factor. Hydrochloric acid helps in the breakdown of proteins during digestion, while intrinsic factor aids in the absorption of vitamin B12 in the small intestine. These two components are crucial for the proper functioning of the digestive system, particularly in breaking down food and absorbing essential nutrients. The liver is involved in bile production, the pancreas in the production of digestive enzymes, and the small intestine in nutrient absorption, but the specific functions related to hydrochloric acid and intrinsic factor are primarily attributed to the stomach.
In order not to frighten small children, it is best to examine things that are uncomfortable or frightening to them last so as not to lose their cooperation. This means the LAST thing to do in a child is, which of the following, EXCEPT________.
- A. Inspection of the throat with a throat stick.
- B. Inspection of the ears with an otoscope
- C. Auscultation of the heart
- D. Undressing the child
Correct Answer: C
Rationale: When examining a child, especially one who may already be feeling scared or uncomfortable, it is important to prioritize the order of procedures to help maintain their cooperation and reduce their anxiety. Undressing the child is typically done first to ensure a thorough examination can be performed, and it is a less invasive procedure compared to others. Inspection of the throat with a throat stick and inspection of the ears with an otoscope are common procedures that may cause mild discomfort but are often tolerated well by children. Auscultation of the heart is usually done after these initial steps and is not typically as uncomfortable or frightening for children compared to other procedures. Therefore, auscultation of the heart should not be the last thing to do when examining a child to avoid frightening them.
Which of the following screening tests is recommended for cervical cancer prevention in women aged 21 to 65 years?
- A. Human papillomavirus (HPV) testing alone
- B. Cytology (Pap smear) alone
- C. Co-testing with cytology and HPV testing
- D. Endometrial biopsy
Correct Answer: B
Rationale: The recommended screening test for cervical cancer prevention in women aged 21 to 65 years is cytology, also known as a Pap smear. The Pap smear is a test that looks for changes in the cells of the cervix that could indicate the presence of cervical cancer or pre-cancerous conditions. This test is recommended every 3 years for women aged 21-29 years, and every 3-5 years for women aged 30-65 years, depending on the screening method used. HPV testing alone or co-testing with both cytology and HPV testing may be used in certain situations, but for most women in this age group, cytology (Pap smear) alone is the recommended screening test.