Nokea
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.
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The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
- A. Gordon’s Functional Health Patterns
- B. Activity-exercise pattern assessment
- C. General to specific assessment
- D. Problem-oriented assessment
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing and the type of drainage present, then will progress to more specific assessments based on the findings. This approach allows for a systematic and comprehensive evaluation of the patient's condition by moving from general observations to detailed examinations.
Explanation:
1. General assessment: The nurse is initially assessing the overall appearance of the surgical dressing and the type of drainage.
2. Specific assessment: Based on the initial findings, the nurse will proceed to conduct more focused assessments, such as checking for signs of infection, monitoring vital signs, and assessing the surgical site for any complications.
Other choices are incorrect:
A: Gordon’s Functional Health Patterns - This framework focuses on assessing different aspects of an individual's health patterns, such as activity level, sleep patterns, and coping mechanisms. It is not the most appropriate approach in this situation.
B: Activity-exercise pattern assessment - This type of assessment focuses
When performing a neurological examination on Mr. RR, which of the following would not be considered an important or useful part of the examination?
- A. Eye movements
- B. Reflexes
- C. Nuchal rigidity
- D. Pupil size NEUROLOGIC MEDICATIONS
Correct Answer: D
Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.
What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
- A. Chlamydia slide
- B. Chlamydia collection kit
- C. Chlamydia swab
- D. Chlamydia wet mount
Correct Answer: B
Rationale: The correct answer is B: Chlamydia collection kit. The primary care provider will need the collection kit to gather a sample for testing. A Chlamydia slide (A) is not necessary as the provider needs to collect a sample first. A Chlamydia swab (C) is used to collect the sample, not to provide to the provider. A Chlamydia wet mount (D) is not appropriate for Chlamydia testing, as it is typically used for other types of infections.
What is the nurse’s firstaction?
- A. Follow the clinical protocol for a stroke.
- B. Review the most recent lab results for the patient’s potassium level. Assess the patient for other symptoms or problems, and then notify the health care
- C. provider. Administer an antihypertensive medication from the stock supply, and then notify the
- D. health care provider.
Correct Answer: B
Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
- A. Gordon’s Functional Health Patterns
- B. Activity-exercise pattern assessment
- C. General to specific assessment
- D. Problem-oriented assessment
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing, which is a general observation, before moving on to more specific details. This approach allows the nurse to gather comprehensive information systematically.
A: Gordon’s Functional Health Patterns involves assessing a patient's health across several categories, not specifically related to wound care.
B: Activity-exercise pattern assessment focuses on the patient's physical activity and exercise routines, not the wound dressing.
D: Problem-oriented assessment involves identifying and addressing specific health issues, rather than starting with a general observation like the appearance of a surgical dressing.