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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
- A. Consider cultural differences during this assessment.
- B. Ask the patient to make eye contact to determine her affect.
- C. Continue with the interview and document that the patient is depressed.
- D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.
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Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
- A. 10% dextrose and saline
- B. 5% dextrose and water
- C. 5% dextrose and water with 60 mEq
- D. Distilled water KCl
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.
An elderly patient, Mr. Cruz is being cared for by nurse Bennie because of pulmonary embolism. Nurse Bennie would anticipate an order for immediate administration of:
- A. warfarin
- B. heparin
- C. dexamethazone
- D. protamine sulfate
Correct Answer: B
Rationale: The correct answer is B: heparin. Heparin is an anticoagulant used for immediate treatment of pulmonary embolism to prevent further clot formation. It acts quickly by inhibiting clotting factors. Warfarin (A) is used for long-term anticoagulation but has a slower onset. Dexamethasone (C) is a corticosteroid used for inflammation, not thrombosis. Protamine sulfate (D) is used to reverse the effects of heparin but is not indicated for initial treatment.
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. The nurse should proceed to the diagnosis step of the nursing process after reviewing the patient's data. In this step, the nurse will analyze the information gathered to identify the patient's health problems and needs. Given the patient's lack of voiding, abnormal kidney function, and decreased oral intake, the nurse needs to determine the underlying issues contributing to these findings. This analysis will guide the nurse in developing a plan of care to address the patient's specific health concerns.
Choice B: Planning would be premature without a clear understanding of the patient's health problems, needs, and contributing factors. Choice C: Implementation would involve carrying out interventions without a thorough understanding of the patient's health issues. Choice D: Evaluation comes after the implementation of interventions to assess their effectiveness, which cannot be done without a clear diagnosis.
In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:
- A. Uterine cervix
- B. Vagina
- C. Uterine body
- D. Fallopian tube
Correct Answer: C
Rationale: The correct answer is C: Uterine body. The rationale is that the most common site of cancer for females is uterine body, specifically endometrial cancer. This is due to the high prevalence of hormonal imbalances and estrogen exposure, which are risk factors for this type of cancer. The other choices, A: Uterine cervix, B: Vagina, and D: Fallopian tube, are less common sites of cancer in females compared to the uterine body. Understanding the prevalence and risk factors associated with each site of cancer is crucial for nurses to educate clients effectively.
A 90 y.o. nursing home resident with stage 2 Alzheimer’s disease is found alone and crying in the dining room. She says she lost her mother and doesn’t know what to do. Which response by the nurse will help calm the resident?
- A. “Remember your mother has been dead for 30 years. You forgot again, didn’t you?”
- B. “I’m sorry you lost your mother; let’s go and try to find her.”
- C. “Are you feeling frightened? I’m here and I will help you.”
- D. “You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do.”
Correct Answer: C
Rationale: The correct answer is C: “Are you feeling frightened? I’m here and I will help you.” This response acknowledges the resident’s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust.
Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.