A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?

Correct Answer: B

Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.

Correct Answer: D

Rationale: The correct answer is D: error in word choices. In left hemisphere stroke, language and speech centers are usually affected, leading to aphasia. This results in errors in word choices, difficulty expressing thoughts, and understanding language. Impulsivity and unsafe activities (choice A) are more commonly associated with frontal lobe damage. Motor deficits on the right eye (choice B) and left side of the body (choice C) are typical in strokes affecting the motor cortex, which is located in the contralateral hemisphere.

Correct Answer: C

Rationale: The correct answer is C: Hypomagnesemia. 1. Hypertension and cardiac dysrhythmias can be exacerbated by low magnesium levels. 2. Magnesium plays a crucial role in maintaining normal heart rhythm and blood pressure. 3. Hypomagnesemia can lead to cardiac arrhythmias and worsen hypertension. 4. Metabolic acidosis (A) is not directly related to hypertension and dysrhythmias. 5. Hypernatremia (B) and hypercalcemia (D) are less likely to be associated with cardiac issues in this context. In summary, checking for hypomagnesemia is essential due to its direct impact on the client's hypertension and cardiac dysrhythmias.

Correct Answer: C

Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion. Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.

Correct Answer: D

Rationale: The correct answer is D: Hypovolemia and shock. Rationale: 1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms. 2. These signs indicate inadequate perfusion due to reduced blood volume. 3. Hypovolemia can progress to shock if not addressed promptly. Summary: A: Compression of blood vessels is not directly related to low blood volume. B: Increasing circulating blood volume would not occur in a client with low blood volume. C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.

Correct Answer: A

Rationale: The correct answer is A: Confusion or delirium can be a defense against further stress. This is because providing new information slowly and in small amounts can help prevent overwhelming Mr. Reyes, who is already confused. This approach allows him to process and understand the information more effectively without adding to his stress levels. Choices B, C, and D are incorrect: B: Destruction of brain cells has occurred, interrupting mental activity - This is not the most appropriate explanation as it assumes irreversible damage to the brain, which is not mentioned in the question. C: Teaching based on information progressing from the simple to the complex - While this may be a valid teaching strategy in general, it does not address Mr. Reyes' specific state of confusion and the need to reduce stress. D: A minimum of information should be given, since he is unaware of surrounding - This choice does not address the underlying reason for providing information slowly, which is to manage stress and confusion, rather than solely focusing on the

Correct Answer: A

Rationale: The correct answer is A: Fluid intake of less than 2,500mL. In diabetes insipidus, the body cannot properly regulate fluid balance, leading to excessive thirst and urination. Successful treatment aims to manage these symptoms by reducing fluid intake to prevent dehydration. Therefore, a decrease in fluid intake indicates successful treatment. Explanation for incorrect choices: B: Blood pressure of 90/50mmHg - Blood pressure is not directly related to the treatment of diabetes insipidus. C: Pulse rate of 126 beats/min - Pulse rate is not a specific indicator of successful treatment for diabetes insipidus. D: Urine output of more than 200mL/hour - In diabetes insipidus, excessive urine output is a symptom of the condition, so an increase in urine output does not indicate successful treatment.

Correct Answer: A

Rationale: The correct answer is A because nosocomial pneumonia occurs in a healthcare setting, such as hospitals or long-term care facilities, where patients are at increased risk due to exposure to pathogens and weakened immune systems. Choice B is incorrect as the timeframe of onset is not limited to within 48 hours of admission. Choice C is incorrect as nosocomial pneumonia can occur in both immunocompromised and immunocompetent hosts. Choice D is incorrect as it refers to pneumonia acquired outside of a healthcare setting.

Correct Answer: B

Rationale: The correct answer is B because the nurse should always prioritize communication with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter could undermine the patient's autonomy and right to be involved in their care. It is important for the nurse to directly address the patient to gather accurate information and ensure patient-centered care. Making eye contact (A), leaning forward (C), and nodding periodically (D) are all appropriate communication techniques that show attentiveness and engagement with the patient, which are crucial in building rapport and trust.