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When the nurse is assessing a patient for pain, what is the most appropriate action to take?
- A. Ask the patient to rate pain intensity
- B. Ask about any allergies
- C. Ask the patient to describe the pain
- D. Measure pain intensity using a scale
Correct Answer: A
Rationale: The correct answer is A because asking the patient to rate pain intensity using a scale (like 0-10) provides a standardized measure of pain perception. This quantitative data helps healthcare providers assess pain severity accurately and track changes over time. Asking about allergies (B) is important but not directly related to pain assessment. Asking the patient to describe the pain (C) provides qualitative information but may not be as reliable or consistent as a numerical rating. Measuring pain intensity using a scale (D) is similar to the correct answer but does not involve the patient's subjective input, which is crucial in pain assessment.
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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
What is the most effective action when a client presents with acute shortness of breath and a history of COPD?
- A. Administer oxygen
- B. Administer antibiotics
- C. Monitor blood glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.
What is the first action the nurse should take when a client develops a deep vein thrombosis (DVT)?
- A. Elevate the affected leg
- B. Apply compression stockings
- C. Provide leg elevation
- D. Administer compression therapy
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain.
Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed.
Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly.
Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.
During a follow-up visit, the nurse discovers that the patient has not been taking his insulin regularly. The nurse asks, "Why haven't you taken your insulin?' Which of the following is an appropriate evaluation of this question?
- A. It may put the patient on the defensive.
- B. It is an innocent attempt to get information.
- C. It would have been better to discuss this with his wife.
- D. It is the best way to discover the reasons for his behaviour.
Correct Answer: A
Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship.
Explanation of other choices:
B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue.
C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy.
D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.
Which factor is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Rationale:
1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members.
2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem.
3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image.
4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image.
Summary:
Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.