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Which of the following is the best choice for an opening statement with a patient who is in distress?
- A. "Nancy, my name is Mrs. C."
- B. "Hello, Mrs. H., my name is Mrs. C. It sure is cold today!"
- C. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
- D. "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
Correct Answer: D
Rationale: The correct answer is D because it directly acknowledges the patient's distress and sets the stage for gathering essential information. By stating the need to ask questions about what happened, it shows empathy and readiness to provide help. Choice A is too formal and lacks empathy. Choice B shifts the focus away from the patient's distress. Choice C is similar to D but lacks the crucial element of acknowledging the patient's emotional state. Thus, D is the best choice for an opening statement in this scenario.
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A nurse is caring for a patient with a history of myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administering pain medication.
- B. Monitoring vital signs and oxygen saturation.
- C. Encouraging deep breathing exercises.
- D. Providing nutritional education.
Correct Answer: B
Rationale: The correct answer is B: Monitoring vital signs and oxygen saturation. This is the priority intervention because it allows the nurse to assess the patient's current cardiac status and detect any potential complications early. Monitoring vital signs provides crucial information on the patient's cardiovascular stability, while oxygen saturation levels indicate adequate tissue perfusion. Administering pain medication (A) can be important but not the priority. Deep breathing exercises (C) and providing nutritional education (D) are important but not as immediate as monitoring vital signs and oxygen saturation in a patient with a history of myocardial infarction.
A nurse is assessing a patient's hydration status. Which of the following findings would suggest dehydration?
- A. Increased urine output
- B. Decreased heart rate
- C. Dry mucous membranes
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.
The nurse is performing a review of systems on a 76-year-old patient. Which of the following statements is correct for this situation?
- A. The questions asked are identical for all ages.
- B. The interviewer will start incorporating different questions for patients 70 years of age and older.
- C. Additional questions are reflective of the normal effects of aging.
- D. At this age, a review of systems is not necessary; just focus on current problems.
Correct Answer: C
Rationale: Rationale: Choice C is correct as additional questions in a review of systems for a 76-year-old patient should address age-related changes. This allows for better assessment of potential health issues specific to older adults. Choice A is incorrect as questions may vary based on age. Choice B is incorrect as age alone does not dictate question changes. Choice D is incorrect as a review of systems is important at all ages for comprehensive patient assessment.
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?' The nurse tells her:
- A. They are signs of decreased hematocrit related to anemia.
- B. They are due to destruction of melanin in your skin due to exposure to the sun.
- C. They are clusters of melanocytes that appear after prolonged sun exposure.
- D. They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction.
Correct Answer: C
Rationale: The correct answer is C because the small, flat, brown macules described are consistent with lentigines (commonly known as age or liver spots), which are clusters of melanocytes that appear after prolonged sun exposure. This explanation directly addresses the patient's question about the cause of the spots and is supported by the clinical presentation.
Choice A is incorrect because decreased hematocrit related to anemia would not cause these specific skin changes. Choice B is incorrect as destruction of melanin due to sun exposure would result in lighter spots, not dark brown macules. Choice D is incorrect because hyperpigmentation related to decreased perfusion and vasoconstriction would present differently and not primarily on sun-exposed areas like the arms and hands.
A nurse is caring for a patient with diabetes who is experiencing symptoms of diabetic neuropathy. The nurse should educate the patient to prioritize which of the following?
- A. Inspecting feet daily for signs of injury.
- B. Exercising to improve circulation.
- C. Eating more protein-rich foods.
- D. Using tight-fitting shoes to prevent blisters.
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetic neuropathy to prevent complications like foot ulcers. Daily foot inspections can catch any signs of injury early, allowing for prompt treatment. It helps in preventing infections and serious complications.
Summary of why other choices are incorrect:
B: Exercising to improve circulation - While exercise is beneficial for overall health, it may not directly address the risk of injury due to neuropathy.
C: Eating more protein-rich foods - While a balanced diet is important for managing diabetes, protein-rich foods do not specifically address the risk of foot injuries in diabetic neuropathy.
D: Using tight-fitting shoes to prevent blisters - Tight-fitting shoes can actually increase the risk of blisters and injuries, especially in patients with diabetic neuropathy.