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Which of the following statements is an example of flight of ideas?
- A. My stomach hurts. Hurts, spurts, burts.
- B. Kiss, wood, reading, ducks, onto, maybe.
- C. Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom.
- D. I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.
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A nurse is caring for a patient with a history of hypertension and heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
- A. Increased urine output and weight loss.
- B. Swelling in the legs and shortness of breath.
- C. Decreased blood pressure and dizziness.
- D. Fatigue and constipation.
Correct Answer: B
Rationale: The correct answer is B: Swelling in the legs and shortness of breath. In heart failure, fluid can build up in the body causing swelling, particularly in the legs. Shortness of breath is a common symptom due to fluid accumulation in the lungs. Increased urine output and weight loss (A) are not indicative of worsening heart failure as they suggest fluid loss. Decreased blood pressure and dizziness (C) can be seen in other conditions like dehydration. Fatigue and constipation (D) are not specific signs of heart failure worsening.
When providing culturally competent care, nurses must incorporate cultural assessment into their health assessment. Which statement is most appropriate to use when initiating a cultural beliefs assessment with a First Nations elder?
- A. Are you of the Christian faith, or another faith?
- B. Do you want to see a medicine man?
- C. How often do you seek help from medical providers?
- D. What cultural or spiritual beliefs are important to you?
Correct Answer: D
Rationale: The correct answer is D: "What cultural or spiritual beliefs are important to you?" This question allows the nurse to understand the elder's values and beliefs, guiding care. A: Assumes a specific faith. B: Stereotypes the elder. C: Focuses on frequency of medical visits, not beliefs.
Which of the following is the best indicator of a patient's nutritional status?
- A. Patient's weight
- B. Serum albumin levels
- C. Patient's food preferences
- D. Number of meals consumed per day
Correct Answer: B
Rationale: The correct answer is B: Serum albumin levels. Serum albumin is a protein produced by the liver and is a key indicator of a patient's nutritional status. Low levels of serum albumin indicate malnutrition or protein deficiency. Monitoring serum albumin levels provides an objective measure of the patient's overall nutritional status.
Choice A (Patient's weight) can be influenced by factors other than nutrition, such as fluid retention or muscle mass. Choice C (Patient's food preferences) does not provide direct information on the patient's actual nutritional intake. Choice D (Number of meals consumed per day) does not account for the quality or quantity of nutrients consumed in those meals.
A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 4.5 kg (10 lb) in the past month. Which of the following is the nurse's best response in this situation?
- A. Do you own any lethal weapon?
- B. How do other people treat you?
- C. Are you feeling so hopeless that you feel like hurting yourself now?
- D. People often feel hopeless, but the feeling resolves within a few weeks.
Correct Answer: C
Rationale: The correct answer is C: "Are you feeling so hopeless that you feel like hurting yourself now?" This response directly addresses the patient's suicidal ideation and assesses the immediate risk of harm. It shows the nurse's concern for the patient's safety and allows for further evaluation and intervention if necessary.
Option A is incorrect because asking about owning a lethal weapon does not directly address the patient's current mental state and immediate risk of harm. Option B is incorrect as it focuses on external factors rather than the patient's internal feelings of hopelessness and suicidal thoughts. Option D is incorrect as it minimizes the seriousness of the patient's symptoms and may lead to overlooking the urgency of the situation.
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following assessments?
- A. Oxygen saturation levels.
- B. Pain levels.
- C. Bowel sounds.
- D. Level of consciousness.
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.