Nokea
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: Option D is the most appropriate statement when assisting a patient with altered thought process and personal hygiene needs. This statement provides the patient with a choice between brushing their teeth independently or having assistance, while also emphasizing the importance of self-care activities. Offering patients choices empowers them and helps maintain their sense of autonomy, even when dealing with altered thought processes. Additionally, encouraging patients to perform activities for themselves can help improve their self-esteem and promote independence.
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A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: D
Rationale: Prolonged aspirin therapy can lead to a rare side effect known as aspirin-induced hearing loss, which manifests as bilateral hearing loss. This adverse reaction is typically associated with higher doses of aspirin and longer durations of use. It is important for healthcare providers to monitor for signs of hearing loss in patients receiving long-term aspirin therapy, especially those with rheumatoid arthritis or other inflammatory conditions, to prevent irreversible damage to the hearing. Weight gain, respiratory acidosis, and fine motor tremors are not commonly associated with prolonged aspirin therapy.
An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct Answer: C
Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.
A medical student observes that infants cry in response to another infant's cry. The MOST appropriate answer is that it represents
- A. an early sign of empathy development
- B. a sign of good hearing
- C. a startle reflex
- D. an early sign of fear development
Correct Answer: A
Rationale: Infants crying in response to others may indicate early empathy development.
Extraneural metastasis from primary brain tumors is MOST commonly likely to occur in which tumor?
- A. medulloblastoma
- B. primitive neuroectodermal tumor (PNET)
- C. ependymoma
- D. malignant glioma
Correct Answer: A
Rationale: Medulloblastoma is notorious for extraneural spread, particularly to bones and bone marrow.
Which statement, from a participant attending the class on AIDS prevention, indicates an understanding on how to reduce transmission of HIV?
- A. Mother's who are HIV positive should still be encouraged to breastfeed their babies because beast milk is superior to cow's milk
- B. I think a needle exchange program, where clean needles are exchanged for dirty needles, should be offered in every city
- C. Females taking birth control pills are protected from getting HIV
- D. It's okay to use natural skin condoms since they offer the same protection as the latex condoms
Correct Answer: B
Rationale: The correct answer is B because implementing a needle exchange program is an effective way to reduce transmission of HIV among intravenous drug users. By providing clean needles in exchange for dirty needles, the risk of sharing contaminated needles and spreading the virus is significantly reduced. This approach also helps prevent the transmission of other bloodborne diseases, such as Hepatitis C. The other statements do not demonstrate an understanding of how to reduce HIV transmission - for example, encouraging breastfeeding for HIV-positive mothers can transmit the virus to the baby, birth control pills do not protect against HIV, and natural skin condoms do not offer the same level of protection as latex condoms.