A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Correct Answer: A

Rationale: In this scenario, the nurse should prioritize the patient's breathing first, followed by addressing the pain and then the sleep issues. The correct answer is option A: Breathing, pain, and sleep. The prioritization is based on the ABCs of nursing - Airway, Breathing, and Circulation. Breathing is a fundamental physiological need that takes precedence over pain and sleep. If a patient is experiencing difficulty breathing, it indicates a potentially life-threatening situation that requires immediate attention to ensure adequate oxygenation. Pain, while important, is considered secondary to breathing as it can often be managed effectively once the patient's respiratory status is stabilized. Sleep, though important for overall well-being, is the lowest priority in this situation as addressing the breathing and pain issues take precedence due to their immediate impact on the patient's health and safety. This question provides a valuable learning opportunity for nursing students to understand the principles of prioritization in patient care based on the ABC framework. It reinforces the critical thinking skills needed to triage and manage multiple patient needs effectively in a clinical setting.

Correct Answer: D

Rationale: In the context of vital signs assessment, this question pertains to detecting hearing loss, a crucial aspect of overall health evaluation. The correct answer, option D - Audiometric testing, is the most sensitive method for detecting hearing loss. Audiometric testing involves a comprehensive evaluation of an individual's hearing capabilities across various frequencies and intensities, providing detailed insights into the extent and nature of any hearing impairment. Option A - The whisper test, is a simple screening tool where the examiner whispers a series of words from a distance to assess if the person being tested can repeat them accurately. While it can indicate potential hearing issues, it lacks the precision and thoroughness of audiometric testing, making it less sensitive for detecting subtle or complex hearing impairments. Option B - The finger rub test, involves rubbing fingers together close to the individual's ear to determine if they can hear the sound. This method is rudimentary and not reliable for accurately diagnosing hearing loss, especially in a clinical setting where precise measurements are necessary. Option C - The tuning fork test, is used to assess conductive hearing loss by comparing air conduction with bone conduction. While it is a valuable diagnostic tool for certain types of hearing loss, it is not as sensitive or comprehensive as audiometric testing in detecting various types and degrees of hearing impairments. In an educational context, understanding the nuances of different hearing tests is essential for healthcare professionals to provide accurate assessments and interventions for patients with hearing concerns. Emphasizing the significance of audiometric testing in diagnosing hearing loss highlights the importance of utilizing evidence-based practices and specialized equipment to ensure optimal patient care and outcomes.

Correct Answer: D

Rationale: At this point, it is important to consider secondary causes for this woman's hypertension because of its severity, rapidity of progression, and lack of response to therapy. While you will most likely add a fourth medicine, it is important to carefully examine the abdomen for the presence of renal artery bruits. These are usually heard best in the upper quadrants. It may be necessary to have the patient hold her breath, to have a very quiet room, and to listen with the diaphragm for a very soft, high-pitched sound with systole. It may also help to simultaneously feel the patient's pulse (a bruit with both a systolic and diastolic component is very specific for a significant blockage, while a lone systolic bruit may not be abnormal). Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and inconvenience of a nephrology referral if you can hear a bruit.

Correct Answer: A

Rationale: In this scenario, when percussing over the liver of a patient and hearing a dull sound, selecting option A) "Consider this a normal finding" is the correct choice. This is because the liver is a solid organ and should produce a dull sound upon percussion due to its density. This finding is considered normal anatomical variation and does not typically indicate any pathology. Option B) "Palpate this area for an underlying mass" is incorrect because a dull percussion sound over the liver does not necessarily suggest the presence of a mass. Palpation may not reveal any abnormalities and could lead to unnecessary concern for the patient. Option C) "Reposition the hands and attempt to percuss in this area again" is unnecessary as the dull sound over the liver is an expected finding. Repetitive percussion may cause discomfort to the patient without providing any additional valuable information. Option D) "Consider this finding as abnormal and refer the patient for additional treatment" is incorrect as a dull percussion sound over the liver is not an abnormal finding requiring immediate referral for treatment. Educationally, understanding the normal percussion sounds of different body organs is crucial for nurses to accurately assess and interpret patient findings. It helps in differentiating between normal variations and pathological conditions, leading to appropriate interventions and patient care.

Correct Answer: D

Rationale: In the nursing process, assessment is the step that involves the systematic collection of data through health history, physical examination, and interviews. This step is crucial as it forms the foundation for all further nursing interventions and decisions. Through assessment, nurses gather essential information about the patient's current health status, which then guides the subsequent steps of the nursing process. Option A, Planning, is incorrect because planning comes after assessment. Once data has been collected through assessment, the nurse then moves on to planning interventions and setting goals based on the assessment findings. Option B, Diagnosis, is incorrect because diagnosis follows the assessment phase. In the nursing process, diagnosis involves analyzing the data collected during assessment to identify the patient's health problems and needs. Option C, Evaluation, is incorrect because evaluation occurs after interventions have been implemented. Evaluation involves assessing the patient's response to the interventions and determining the effectiveness of the care provided. Understanding the sequential nature of the nursing process is essential for nurses to provide comprehensive and effective care to their patients. By correctly identifying assessment as the step involving data collection, nurses can ensure they have a solid foundation on which to base their subsequent nursing actions.