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: C

Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications. A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain. B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain. D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.

Correct Answer: B

Rationale: Rationale: Answer B is correct because a hemoglobin level of 11mg/dl and hematocrit level of 32% in a 78-year-old client are indicative of anemia. Conducting a thorough nutritional assessment is essential to identify potential causes of anemia such as iron deficiency or vitamin deficiencies. This assessment will help determine appropriate interventions to manage the anemia. Summary: A: Incorrect. These levels are indicative of anemia, not normal findings. C: Incorrect. Advising to repeat the test in three months may delay necessary interventions for the anemia. D: Incorrect. While anemia can be related to bone marrow degeneration, a nutritional assessment is needed to identify the specific cause in this case.

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: A

Rationale: The correct answer is A: White patches on the tonsils. Group A streptococci infection commonly presents with exudative tonsillitis, characterized by the presence of white patches or pus on the tonsils. This is due to the inflammatory response triggered by the bacteria. Hypertrophied tonsils (B), hemorrhage in the tonsils (C), and bleeding in the tonsils (D) are less likely to be visual signs of a streptococcal infection and are more indicative of other conditions or complications. Therefore, white patches on the tonsils are the most specific visual sign associated with group A streptococci tonsillar infection.

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: C

Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer indicates a perforation of the ulcer. Perforation leads to leakage of gastric contents into the peritoneal cavity, causing peritonitis. This presentation requires immediate surgical intervention. Option A is incorrect as intestinal development does not correlate with the symptoms described. Option B is incorrect because inflammation of the esophagus would not lead to a rigid boardlike abdomen. Option D is incorrect as the sudden onset of symptoms is more indicative of a complication like perforation rather than the development of additional ulcers.

Correct Answer: D

Rationale: The correct answer is D because assessing for localized ischemia involves evaluating multiple factors. A: Assessing color and temperature helps determine perfusion. B: Checking capillary refill assesses circulation. C: Evaluating pulse rate indicates cardiac output. Doing all of the above provides a comprehensive assessment of arterial flow and potential ischemia. Other choices are incorrect as they do not cover all aspects necessary for a thorough assessment.

Correct Answer: C

Rationale: The correct answer is C. Wearing protective gear such as gown, mask, gloves, and goggles when entering the room is crucial to prevent infection in patients with AIDS. This intervention helps to minimize the risk of transmitting pathogens to the patient and vice versa. The protective gear acts as a barrier to prevent the spread of infectious agents. It also protects healthcare workers from exposure to potentially harmful pathogens. Prohibiting visitors who are severely immunodeficient (choice A) may be isolating for the patient and does not directly address preventing infection transmission. Prohibiting visitors with a cough (choice B) is important but does not cover all potential sources of infection. Ensuring protective barrier isolation precautions are in place (choice D) is a general statement and does not specify the practical steps needed to prevent infection transmission effectively.