To start a nursing improvement project, what is the FIRST step that a nurse must keep in mind?

Correct Answer: B

Rationale: The first step that a nurse must keep in mind to start a nursing improvement project is to determine the nursing standards. This is crucial because nursing standards provide guidelines and benchmarks for quality care delivery. By identifying and understanding the established standards, nurses can assess current practices, identify areas that need improvement, and develop strategies to enhance patient care. Setting a clear foundation based on nursing standards is essential before moving forward with implementing corrective actions, determining findings for correction, or collecting data. Understanding and aligning with nursing standards from the outset ensures that the improvement project is focused on promoting best practices and achieving positive outcomes for patients.

Correct Answer: A

Rationale: Difficulty of speaking and chewing is an indicator of cranial nerve involvement. Cranial nerves are responsible for controlling various functions of the head and neck, including speech and mastication. Impairment of cranial nerve function can lead to difficulty in these activities. In the context of the question, with the patient in the stroke unit, cranial nerve involvement can occur due to the stroke affecting the brain regions responsible for cranial nerve function. Loss of pain sensation, spastic paralysis of the extremities, and forgetfulness with syncope are not specific indicators of cranial nerve involvement in this scenario.

Correct Answer: B

Rationale: In order to understand and interpret a message accurately, it is essential to consider the context in which it was delivered. Context provides the necessary background information, setting, and circumstances that give meaning and relevance to the message being communicated. Without context, it can be challenging to fully grasp the intention and significance of the communication. While the other options (process, phrases and sentences, thoughts and feelings) play roles in communication, it is the context that ultimately helps to give meaning and context to the message being conveyed.

Correct Answer: C

Rationale: When discharging a suicidal patient who has been taking tricyclic antidepressant drugs, it is crucial for the nurse to evaluate the risk for suicide by overdose of the medication. Tricyclic antidepressants have a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose can be quite small. This makes them particularly dangerous in cases of overdose, as they can lead to severe toxic effects, including cardiac arrhythmias, seizures, and death.

Correct Answer: B

Rationale: The most appropriate nursing diagnosis for the individual described is "Ineffective individual coping." This is because the individual has been facing challenges in both academic (failing math class) and personal (substance dependence) aspects of his life. The repeated failures in his math class and the substance dependence for three years indicate that he might be struggling to cope with stressors and challenges in his life effectively. By identifying this nursing diagnosis, the nurse can focus on helping the individual develop effective coping strategies to manage and overcome these difficulties.