Nokea
Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?
- A. Perform a neurological assessment
- B. Initiate a stroke protocol
- C. Position the client on their side
- D. Start a CT scan
Correct Answer: B
Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.
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A nurse is teaching a patient with diabetes about managing diabetic neuropathy. Which of the following statements by the patient indicates the need for further education?
- A. I should inspect my feet daily for cuts or blisters.
- B. I can wear tight shoes to avoid blisters.
- C. I should avoid walking barefoot to prevent injuries.
- D. I should keep my blood glucose levels within the target range.
Correct Answer: B
Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
- A. "It is a sharp, burning pain in my stomach."
- B. "I also have the sweats and nausea when I feel this pain."
- C. "I think this pain is telling me that something is wrong with me."
- D. "This pain happens every time I sit down to use the computer."
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Pulmonary edema.
- C. Anemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs causing pulmonary edema. This can result in symptoms such as shortness of breath, coughing, and wheezing. Monitoring for pulmonary edema is crucial in heart failure management to prevent respiratory distress and worsening heart function.
Rationale:
A: Hypoglycemia - While patients with heart failure may be at risk for metabolic abnormalities, hypoglycemia is not a common complication directly related to heart failure.
C: Anemia - Anemia can occur in heart failure due to reduced oxygen-carrying capacity of the blood, but it is not a direct complication that requires immediate monitoring like pulmonary edema.
D: Hypertension - Heart failure is characterized by a reduced ability of the heart to pump blood effectively, leading to decreased cardiac output. Therefore, hypertension is not typically a complication seen in heart failure patients.
A 32-year-old patient shares with the nurse that she has been unwell for 2 weeks. She has had a variety of symptoms and has been treating them with herbs that her mother has provideThe nurse should:
- A. tell the patient that it is the herbs that are making her feel unwell.
- B. ask the patient more about the effects of the herbs.
- C. take a sample of the herbs to send to the laboratory for analysis.
- D. ask the patient's mother to explain the use of the herbs.
Correct Answer: B
Rationale: The correct answer is B because the nurse needs more information to assess the situation effectively. By asking the patient more about the effects of the herbs, the nurse can gather crucial details about the patient's condition and the potential impact of the herbs on her health. This will help the nurse make an informed decision on the appropriate course of action.
Choice A is incorrect because jumping to conclusions without gathering more information can be detrimental to the patient's care. Choice C is incorrect as sending the herbs for analysis may not provide immediate insights into the patient's condition. Choice D is incorrect as the focus should be on directly obtaining information from the patient rather than involving a third party.
When formulating diagnostic statements, what would the nurse use?
- A. Rationale
- B. American Nurses Association recommendations
- C. Physical assessment skills
- D. Diagnostic reasoning
Correct Answer: D
Rationale: The correct answer is D: Diagnostic reasoning. When formulating diagnostic statements, nurses use diagnostic reasoning to analyze data, identify patterns, and make accurate clinical judgments. This process involves critical thinking and synthesizing information to reach a conclusion. Physical assessment skills (C) are important in data collection but not the primary focus in formulating diagnostic statements. Rationale (A) refers to providing reasons or justifications and is not directly related to the diagnostic process. American Nurses Association recommendations (B) may guide nursing practice but are not specifically used in formulating diagnostic statements.