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While auscultating for heart sounds, the nurse hears an unfamiliar sounWhat should the nurse do next?
- A. Document the findings on the patient's record.
- B. Wait 10 minutes, and auscultate the heart again.
- C. Ask another nurse to double-check the finding.
- D. Ask the patient to take deep breaths and check for changes in their physical condition.
Correct Answer: A
Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.
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A nurse is teaching a patient with asthma about proper inhaler use. Which of the following statements by the patient indicates the need for further education?
- A. I should hold my breath for 10 seconds after inhaling the medication.
- B. I should use my inhaler before exercise to prevent symptoms.
- C. I can use my inhaler every 30 minutes if I have trouble breathing.
- D. I should rinse my mouth after using my inhaler to prevent thrush.
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every 30 minutes for trouble breathing is not recommended. Overuse can lead to medication side effects and potential worsening of symptoms.
A: Holding breath after inhaling helps medication reach lungs.
B: Using inhaler before exercise can prevent exercise-induced symptoms.
D: Rinsing mouth prevents thrush, a common side effect of inhaled corticosteroids.
During an interview, the nurse asks the patient to tell more about their shortness of breath. What is the verbal skill used?
- A. Reflection
- B. Facilitation
- C. Direct question
- D. Open-ended question
Correct Answer: D
Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.
A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?
- A. Increasing sodium intake.
- B. Losing weight and increasing physical activity.
- C. Consuming more processed foods.
- D. Limiting fluid intake.
Correct Answer: B
Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels.
A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure.
C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure.
D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.
A 75-year-old woman is at the clinic for a preoperative interview. The nurse is aware that the interview with her may take longer than interviews with younger persons. What is the reason for this?
- A. An older adult has a longer story to tell.
- B. An older adult is usually lonely and likes to have someone to talk to.
- C. Older adults lose much of their mental abilities and require more time to complete an interview.
- D. As a person ages, he or she is unable to hear well, so interviewers usually need to frequently repeat what they say.
Correct Answer: A
Rationale: The correct answer is A because as people age, they accumulate more life experiences, medical history, and details to share. This can lead to longer conversations during interviews. Choice B is incorrect as not all older adults are lonely and seek conversation. Choice C is incorrect because aging does not necessarily equate to a loss of mental abilities. Choice D is incorrect as hearing loss is not a universal issue among older adults and does not significantly impact the length of interviews.
A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, she is unable to differentiate between hot and cold and is unsure of how to dress for the weather. This is an example of:
- A. Mania.
- B. Agnosia.
- C. Dementia.
- D. Amnestic disorder.
Correct Answer: B
Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia.
A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues.
C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits.
D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.