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Which of the following questions would best assess a person's judgement?
- A. Do you feel that you are being watched, followed, or controlled?
- B. Tell me about what you plan to do once you are discharged from the hospital.
- C. What does the saying, "People in glass houses shouldn't throw stones' mean to you?
- D. What would you do if you found a stamped, addressed envelope on the sidewalk?
Correct Answer: B
Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.
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A nurse is caring for a patient with chronic asthma. The nurse should monitor the patient for which of the following complications of asthma?
- A. Hypoglycemia.
- B. Oxygen toxicity.
- C. Hyperkalemia.
- D. Respiratory failure.
Correct Answer: D
Rationale: The correct answer is D: Respiratory failure. In chronic asthma, persistent inflammation and airway remodeling can lead to worsening lung function and respiratory distress, ultimately resulting in respiratory failure. Monitoring for signs of respiratory distress such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.
A: Hypoglycemia is not a typical complication of asthma.
B: Oxygen toxicity is not a common complication in asthma management unless high concentrations of supplemental oxygen are administered for prolonged periods.
C: Hyperkalemia is not directly associated with asthma but may occur as a complication of certain asthma treatments or comorbid conditions.
Therefore, the priority complication to monitor in a patient with chronic asthma is respiratory failure due to the progressive nature of the disease and the potential for acute exacerbations.
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but laughs loudly when looking at it. This behaviour is a display of:
- A. Confusion.
- B. Ambivalence.
- C. Depersonalization.
- D. Inappropriate affect.
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response.
A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it.
B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior.
C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior.
In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
- A. nursing diagnosis.
- B. medical diagnosis.
- C. admission diagnosis.
- D. collaborative diagnosis.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs.
2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions.
3. It guides nurses in planning individualized care to meet patient's specific needs.
4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care.
5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission.
6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care.
Summary:
The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.
The nurse notices that the patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:
- A. Bulla.
- B. Wheal.
- C. Nodule.
- D. Papule.
Correct Answer: D
Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites.
A: Bulla is a large fluid-filled blister, not a solid lesion.
B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction.
C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.
The nurse is conducting a health interview with a patient named Salil. There is a language barrier, and no interpreter is available. Which of the following is the best example of an appropriate question for the nurse to ask in this situation?
- A. "Does Salil take medicine?"
- B. "Do you sterilize the bottles?"
- C. "Do you have nausea and vomiting?"
- D. "He has been taking his medicine, hasn't he?"
Correct Answer: A
Rationale: The correct answer is A: "Does Salil take medicine?" This is the best question because it is simple, direct, and focuses on gathering important medical information. It is clear and easy to understand even with a language barrier. Choice B is irrelevant and not related to the patient's health status. Choice C assumes symptoms without context. Choice D is inappropriate as it refers to the patient in the third person and includes a leading statement. Asking about medication directly is the most appropriate approach in this scenario.