Which of the following questions or statements would be an appropriate termination of the health history interview?
- A. “Well, I can’t think of anything else to ask you right now.”
- B. “Can you think of anything else you would like to tell me?”
- C. “I wish you could have remembered more about your illness.”
- D. “Perhaps we can talk again sometime. Goodbye.”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.
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A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?
- A. I have assessed you and find you are fatigued.
- B. I analyzed and interpreted your information as fatigue.
- C. Why are you so tired all the time?
- D. I think fatigue is a problem for you. Do you agree?
Correct Answer: D
Rationale: The correct answer is D because it involves collaboration with the client to validate their experience. It shows respect for the client's perspective and promotes open communication. Choice A is incorrect as it lacks client involvement. Choice B is incorrect as it focuses on the nurse's interpretation rather than the client's experience. Choice C is incorrect as it may come off as accusatory or judgmental, lacking empathy.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be observed or measured by others. In this case, choice C is correct because the patient describing excitement about discharge is personal and based on the patient's feelings or perceptions. This is subjective data because it is based on the patient's own experiences and emotions. Choices A and B are incorrect because patient's temperature and wound appearance are objective data that can be measured or observed by the nurse. Choice D is also incorrect as patient pacing the floor is an observable behavior, making it objective data. Therefore, choice C is the correct answer as it represents subjective data in the context of the assessment.
A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
- A. Onset of sporadic sexual activity at age 17
- B. Spontaneous abortion at age 19
- C. Pregnancy complicated with eclampsia at age 27
- D. Human papilloma virus infection at age 32
Correct Answer: D
Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV infection is a well-known risk factor for cervical cancer as certain strains of HPV can lead to cellular changes in the cervix that may progress to cancer. Here's the rationale:
1. HPV is a known risk factor: HPV is a sexually transmitted infection that is strongly linked to the development of cervical cancer.
2. Age of infection: The client's history of acquiring HPV at age 32 is significant as long-standing HPV infection increases the risk of cervical cancer.
3. Other choices are not directly linked: Choices A, B, and C are not directly associated with an increased risk of cervical cancer. Age of sexual activity onset, spontaneous abortion, and eclampsia are not established risk factors for cervical cancer.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: The correct answer is A: Expressive aphasia and paralysis on the right side of the body. In a right-handed person, the left side of the brain controls language and right-sided motor function. A stroke affecting the left side of the cortex would lead to expressive aphasia due to damage to Broca's area, causing difficulty in speaking and forming words. Paralysis on the right side of the body would result from damage to the motor cortex in the left hemisphere. Choices B, C, and D are incorrect because they do not align with the typical deficits seen in a person with a stroke affecting the left side of the cortex in a right-handed individual.