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Which technique or method is used to determine whether or not the patient has an irregular pulse?
- A. Apical pulse
- B. Inspection
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: An apical pulse check is used to determine if the patient has an irregular pulse. The apical pulse is located at the point of maximal impulse (PMI) and is assessed using a stethoscope. Choice B, inspection, involves visual examination and is not used to assess pulse irregularities. Choice C, auscultation, involves listening to internal sounds using a stethoscope, which can be used to assess heart sounds but not specifically for pulse irregularities. Choice D, percussion, is a technique used to assess the density of body tissues or detect abnormal masses and is not used to determine pulse irregularities.
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What are the six levels of consciousness from the most to the least responsive level of consciousness? Number all six using 1 as the most conscious and 6 as the least conscious.
- A. Obtunded, Confused, Lethargic, Comatose, Stuporous, Alert
- B. Confused, Lethargic, Obtunded, Stuporous, Comatose, Alert
- C. Lethargic, Obtunded, Confused, Stuporous, Comatose, Alert
- D. Alert, Confused, Lethargic, Obtunded, Stuporous, Comatose
Correct Answer: D
Rationale: The correct order of the six levels of consciousness from most to least responsive is Alert, Confused, Lethargic, Obtunded, Stuporous, Comatose. Choice A is incorrect because it starts with Obtunded, which is less responsive than Alert. Choice B is incorrect as it doesn't follow the correct order. Choice C is incorrect as Lethargic is more responsive than Obtunded. Therefore, the correct answer is D.
You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?
- A. It is normal among adolescents.
- B. It indicates that the patient has an intact peripheral nervous system.
- C. It indicates that the patient has an intact central nervous system.
- D. It is not a normal finding.
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.
A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
- A. Elevating the head of the client's bed to 30 degrees during mealtime
- B. Withholding fluids until the end of the meal
- C. Providing a 10-minute rest period prior to meals
- D. Instructing the client to place her chin toward her chest when swallowing
Correct Answer: D
Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.
A client diagnosed with type 1 diabetes receives insulin. He asks the nurse why he can't just take pills instead. What is the best response by the nurse?
- A. Insulin must be injected because it needs to work quickly.
- B. Insulin can't be in a pill because it is destroyed in stomach acid.
- C. Have you talked to your doctor about taking pills instead?
- D. I know it is tough, but you will get used to the shots soon.
Correct Answer: B
Rationale: The correct answer is B because insulin cannot be taken orally as it gets destroyed by stomach acid. Choice A is incorrect as the speed of action is not the reason why insulin can't be in pill form. Choice C is incorrect as it doesn't address the nature of insulin. Choice D is incorrect as it doesn't provide a factual reason why insulin can't be in pill form.
A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
- A. Request another family member to assist the client's partner with care
- B. Recommend the partner to place the client in a long-term care facility
- C. Contact the case manager to discuss discharge options
- D. Ask the provider to delay the client's discharge home for a few more days
Correct Answer: C
Rationale: The nurse should contact the case manager to discuss discharge options and support the client's partner. This action is appropriate as it involves seeking professional guidance and support for the client's partner who is struggling to care for the client. Option A is not the best choice as it solely focuses on involving another family member without addressing the partner's concerns directly. Option B is premature as recommending long-term care should be a well-considered decision involving multiple healthcare professionals. Option D delays the inevitable without providing a solution to the partner's current challenges.