During a home visit, a member of the family you're visiting who has been using marijuana for three years tells theyou that he wants to be 'detoxified'. It is important for the nurse to ____.

Correct Answer: B

Rationale: Identifying the patient's stage of change is crucial when someone expresses a desire to be "detoxified" from a substance like marijuana. The Transtheoretical Model (Stages of Change) outlines different stages individuals go through when making behavior changes. By identifying which stage the patient is in (precontemplation, contemplation, preparation, action, maintenance, or relapse), the nurse can tailor interventions and support accordingly. This approach helps ensure that interventions are effective and appropriate for the individual's readiness for change. It is important to meet the patient where they are in their journey towards detoxification and offer support and guidance accordingly.

Correct Answer: C

Rationale: The suicide of her mother is the most probable historical data that led to post-traumatic stress disorder. Experiencing the suicide of a close family member, especially a parent, can be an extremely traumatic event that can have long-lasting psychological effects. Witnessing or dealing with such a tragic loss can lead to feelings of helplessness, depression, guilt, and intense emotional distress, all of which are common in individuals with post-traumatic stress disorder (PTSD). This significant and distressing event could have a profound impact on the individual's mental health and well-being, contributing to the development of PTSD symptoms such as intrusive memories, avoidance behaviors, negative mood alterations, and changes in arousal or reactivity.

Correct Answer: B

Rationale: When a patient is unable to talk, the nurse can best communicate with the patient by using picture cards. Picture cards can help the patient convey their needs, feelings, or responses by pointing to the corresponding pictures. This method allows for effective communication and understanding between the patient and the nurse, even when verbal communication is not possible. It promotes patient autonomy and ensures that their needs are accurately communicated and addressed. Additionally, picture cards can be a useful tool in reducing frustration and anxiety for patients who are unable to communicate verbally.

Correct Answer: A

Rationale: The patient presents with gradual, painless visual field loss in both eyes, particularly in the peripheral vision, which is characteristic of glaucoma. The elevated intraocular pressure (IOP) on tonometry further supports a diagnosis of glaucoma. Open-angle glaucoma is the most common type of glaucoma and typically presents insidiously with a slow progression of vision loss. In open-angle glaucoma, the drainage angle of the eye remains open but becomes less efficient over time, leading to increased intraocular pressure and optic nerve damage. This results in peripheral visual field loss. Closed-angle glaucoma, on the other hand, presents more acutely with sudden eye pain, redness, and blurred vision due to a sudden increase in intraocular pressure from a blocked drainage angle. Age-related macular degeneration and diabetic retinopathy typically do not present with elevated IOP or peripheral visual field loss.

Correct Answer: D

Rationale: Since Nadine is just four years old, determining her favorite toys is not a critical aspect for Nurse Alma to consider in terms of routines and rituals. While knowing Nadine's favorite toys may help provide comfort or distraction, it is not as essential as ensuring proper feeding, sleep patterns, and toilet training for a young child's well-being and development. The focus should primarily be on aspects that directly impact her physical health, growth, and daily routines at this age.

Correct Answer: B

Rationale: Validity refers to the extent to which a test accurately measures what it is intended to measure. In the context of screening tests for diseases, validity is crucial in assessing whether the test can correctly distinguish between individuals who have the disease (true positives) and those who do not have the disease (true negatives). This includes the ability to minimize false positives (incorrectly identifying someone as having the disease) and false negatives (incorrectly identifying someone as not having the disease). Therefore, when assessing the ability of a screening test to distinguish correctly between persons with and without a disease, we are essentially evaluating its validity.

Correct Answer: C

Rationale: One of the main consequences of hypoxemia, which is low oxygen levels in the blood, is decreased oxygen saturation. Oxygen saturation refers to the percentage of hemoglobin molecules in the blood that are bound to oxygen. When there is insufficient oxygen in the blood due to hypoxemia, the oxygen saturation levels will drop. This can lead to symptoms such as shortness of breath, confusion, rapid heart rate, and ultimately can result in tissue damage if not corrected promptly. Monitoring oxygen saturation levels is crucial in the immediate post-operative phase to ensure adequate ventilation and oxygenation for the patient's recovery.

Correct Answer: A

Rationale: The patient's presentation of sudden-onset, painless vision loss in the right eye, along with a cherry-red spot at the macula and attenuated retinal vessels, is classic for central retinal artery occlusion (CRAO). In CRAO, there is a sudden blockage of the central retinal artery, leading to ischemia of the retina. The cherry-red spot represents the preserved choroid blood flow against the ischemic retina. The attenuated retinal vessels are a result of decreased blood flow in the retinal circulation. This condition is considered an ophthalmic emergency and requires immediate evaluation and management to prevent permanent vision loss.

Correct Answer: A

Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.