A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?

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Question 1 of 5

A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?

Correct Answer: D

Rationale: Correct Answer: D - Administering oxygen Rationale: 1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload. 2. Administering oxygen helps alleviate ischemia and prevents further damage. 3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being. Summary of other choices: A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction. B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation. C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.

Question 2 of 5

A man has been admitted to the observation unit after having been treated for a large cut on his foreheaAs the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, "I quit smoking after my wife died 7 years ago." However, the nurse notices an open packet of cigarettes in his shirt pocket. If using confrontation as a response, the nurse could say:

Correct Answer: D

Rationale: The correct answer is D because using confrontation in this situation involves addressing the discrepancy between the patient's statement and observed behavior without being aggressive or judgmental. By stating, "Mr. K., I know that you are lying," the nurse directly addresses the inconsistency, encouraging honesty and open communication. This approach can help build trust and facilitate a more honest discussion about the patient's tobacco use. Choice A is incorrect as it is too direct and may come across as accusatory. Choice B is also incorrect as it does not acknowledge the discrepancy and may not lead to a productive conversation. Choice C is incorrect as it avoids addressing the issue and focuses on the patient's personal situation instead of the behavior in question.

Question 3 of 5

A nurse is taking health history from a patient. The nurse observes the patient's nonverbal behaviors such as hand wringing, avoiding eye contact, and shifting in the seat. Which of the following would be an appropriate response by the nurse?

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and addresses the patient's potential emotions directly. By asking if the patient feels nervous or worried about the pregnancy, the nurse acknowledges the observed nonverbal behaviors and opens the door for the patient to express their feelings. This approach shows sensitivity and may help the patient feel understood and supported. Choice A is incorrect because directly asking the patient to explain what they are feeling might come off as intrusive and could make the patient uncomfortable. Choice B is not ideal as remaining silent may lead to missed opportunities for the patient to share their concerns. Choice D, while important, does not address the specific nonverbal cues observed and may not prompt the patient to open up about their emotions.

Question 4 of 5

What is the nurse's most appropriate response when a patient with hearing impairment is encountered?

Correct Answer: A

Rationale: The correct answer is A: Assess the communication method preferred by the patient. This response is appropriate because it demonstrates person-centered care by respecting the patient's communication preferences. By assessing the patient's preferred communication method, the nurse can effectively communicate with the patient and provide the best care. Summary of other choices: B: Requesting a sign language interpreter may not be necessary if the patient does not use sign language. C: Using loud and exaggerated facial movements can be demeaning and ineffective in communication. D: Assuming all older adults have hearing deficits is a stereotype and may not be accurate for every individual.

Question 5 of 5

When the nurse is assessing a patient for pain, what is the most appropriate action to take?

Correct Answer: A

Rationale: The correct answer is A because asking the patient to rate pain intensity using a scale (like 0-10) provides a standardized measure of pain perception. This quantitative data helps healthcare providers assess pain severity accurately and track changes over time. Asking about allergies (B) is important but not directly related to pain assessment. Asking the patient to describe the pain (C) provides qualitative information but may not be as reliable or consistent as a numerical rating. Measuring pain intensity using a scale (D) is similar to the correct answer but does not involve the patient's subjective input, which is crucial in pain assessment.

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