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Which technique should be used to assess a murmur in a patient's heart?
- A. The bell of the stethoscope
- B. The diaphragm of the stethoscope
- C. Palpation with the palm of the hand
- D. Ask another nurse to double-check the finding.
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location.
A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs.
C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs.
D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.
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Which of the following statements illustrates the biomedical model of Western traditional views?
- A. Health is viewed as the absence of disease.
- B. Optimal health is viewed as high-level wellness.
- C. Health and disease are considered parts of a cyclical process.
- D. The treatment of disease is nursing's primary focus.
Correct Answer: A
Rationale: The correct answer is A because the biomedical model focuses on defining health as the absence of disease. This model emphasizes biological factors in understanding and treating illnesses. It is reductionist in nature, viewing health issues as purely physical and separate from social or psychological aspects. Choices B, C, and D do not align with the biomedical model. B emphasizes overall well-being, not just the absence of disease. C suggests a more holistic approach, while D implies a focus on nursing rather than the medical model's emphasis on disease treatment.
A nurse is caring for a patient with a history of hypertension. The nurse should prioritize which of the following interventions?
- A. Administering antihypertensive medication as prescribed.
- B. Encouraging weight loss.
- C. Monitoring blood pressure regularly.
- D. Promoting a low-sodium diet.
Correct Answer: A
Rationale: The correct answer is A: Administering antihypertensive medication as prescribed. This is the priority intervention because it directly addresses the patient's hypertension, which is a critical condition that needs immediate management to prevent complications. Encouraging weight loss (B), monitoring blood pressure (C), and promoting a low-sodium diet (D) are all important aspects of managing hypertension. However, administering antihypertensive medication takes precedence as it directly targets lowering blood pressure and reducing the risk of cardiovascular events. Weight loss, monitoring, and dietary changes are important for long-term management but may not provide immediate control of hypertension compared to medication.
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this a normal finding, and proceed with the abdominal assessment.
- C. Use less force to percuss over the abdomen.
- D. Use more force to percuss over the abdomen.
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
A First Nations family requires dental care. The nurse needs to determine which of the following in order to facilitate the best possible care for this family?
- A. Do they have coverage under the Indian Act of 1876?
- B. Do they live on a reservation or in town?
- C. Do they have noninsured health benefits?
- D. Do they have their provincial health cards?
Correct Answer: C
Rationale: The correct answer is C: Do they have noninsured health benefits? This is because noninsured health benefits provide coverage for essential health services not covered by other plans for First Nations and Inuit people in Canada. It ensures access to necessary dental care for the family.
Incorrect choices:
A: Coverage under the Indian Act of 1876 is not directly related to accessing dental care; it pertains to legal and historical rights.
B: Living on a reservation or in town may not necessarily impact access to dental care, as healthcare services can vary.
D: Having provincial health cards is important for general healthcare, but specific benefits for First Nations may not be covered.
A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be:
- A. Lethargic.
- B. Obtunded.
- C. Stuporous.
- D. Semialert.
Correct Answer: A
Rationale: The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic.
Explanation for other choices:
B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse.
C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness.
D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.