Nokea
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 rather than depression. The nurse should be culturally sensitive and understand that different cultures have varying communication norms. By considering cultural differences, the nurse can build rapport and trust with the patient. Asking the patient to make eye contact (B) may be perceived as disrespectful and may hinder effective communication. Continuing with the interview and assuming depression (C) without further assessment is premature and may lead to misdiagnosis. Notifying the health care provider for a psychological evaluation (D) is not necessary at this stage as the behavior observed may be culturally influenced.
You may also like to solve these questions
The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
- A. Gathers and organizes needed supplies
- B. Decides on goals and outcomes for the patient
- C. Assesses the patient’s readiness for the procedure
- D. Calls for assistance from another nursing staff member
Correct Answer: A
Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.
A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
- A. It’s normal and requires no action
- B. It calls for a repeat Pap test in 6 weeks
- C. It calls for a repeat Pap test in 3 months
- D. It calls for a biopsy as soon as possible
Correct Answer: D
Rationale: The correct answer is D because a class V finding on a Pap test indicates severe dysplasia or carcinoma in situ, which requires further evaluation through a biopsy to confirm the presence of abnormal cells. This finding is not normal and necessitates immediate action for diagnosis and potential treatment. Choices A, B, and C are incorrect because they do not address the urgency and seriousness of a class V finding, which mandates prompt follow-up to rule out or confirm the presence of precancerous or cancerous cells.
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.
Which of the ff. type of eyedrops does the nurse understand is given to constrict the pupil, permitting aqueous humor to flow around the lens?
- A. Osmotic
- B. Mydriatic
- C. Myotic
- D. Cycloplegic
Correct Answer: C
Rationale: The correct answer is C: Myotic. Myotic eyedrops constrict the pupil, allowing aqueous humor to flow around the lens. Myotic agents, such as pilocarpine, work by stimulating the sphincter muscle of the iris. Osmotic eyedrops (A) reduce intraocular pressure, mydriatic eyedrops (B) dilate the pupil, and cycloplegic eyedrops (D) paralyze the ciliary muscle to prevent accommodation.
A 57-year old patient had a right lower lobectomy. The nurse should initiate this action when the patient arrives from the Post Anesthesia Care Unit:
- A. immediately administer pain relief
- B. keep patient in semi-fowler’s postion
- C. turn client every hour
- D. notify the family to report pateint’s condition
Correct Answer: A
Rationale: The correct answer is A: immediately administer pain relief. After a lobectomy, the patient may experience significant pain due to the surgical incision and chest tube insertion. Providing prompt pain relief is crucial to ensure the patient's comfort and prevent complications such as shallow breathing or limited mobility. This action will also aid in the patient's early recovery and promote better outcomes.
Choice B (keep patient in semi-fowler's position) is not the priority upon arrival from the Post Anesthesia Care Unit as pain management takes precedence. Choice C (turn client every hour) is important for preventing complications but is not the immediate action required upon arrival. Choice D (notify the family to report patient's condition) is important but not as urgent as providing pain relief to the patient.