When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior?

Correct Answer: A

Rationale: The best response for the nurse to give in this situation is option A) Be silent, and allow him to continue when he is ready. This response is the most appropriate because the patient's pauses and expectant looks indicate that he may need time to gather his thoughts or express himself. Being silent and giving the patient space allows him to feel heard and respected, facilitating better communication. Option B is incorrect because although it aims to reassure the patient, it may also come off as dismissive or patronizing, potentially shutting down the patient's communication. Option C is wrong as it may make the patient feel self-conscious about his behavior, potentially hindering open and honest communication. Option D is not the best response because it assumes the patient is uncomfortable without any clear indication of this. It may prematurely end the conversation and potentially miss important information the patient wants to share. In an educational context, it's crucial for healthcare professionals to understand the importance of active listening and nonverbal communication in patient interactions. Pauses and expectant looks can be cues for deeper emotions or thoughts that the patient may be struggling to articulate. By allowing the patient time and space to express themselves, nurses can build trust, gather more accurate information, and provide better patient-centered care.

Correct Answer: B

Rationale: In assessing a patient with significant shortness of breath, the nurse should focus on areas related to the respiratory system first (Option B) because shortness of breath is a critical respiratory symptom that requires immediate attention. By prioritizing the respiratory system, the nurse can quickly assess for potential issues such as respiratory distress, airway obstruction, or inadequate oxygenation. This approach allows for timely intervention and management of the patient's breathing difficulties. Option A is incorrect because performing a complete physical assessment immediately may waste precious time that could be crucial in addressing the patient's respiratory distress. Option C is incorrect as asking the patient to lie flat can worsen their breathing difficulties, especially if they are experiencing respiratory distress. Option D is incorrect as obtaining a detailed history from a family member may delay necessary interventions that require immediate attention. Educationally, understanding the prioritization of assessments based on the patient's presenting symptoms is crucial for nurses to provide safe and effective care. It highlights the importance of quick thinking and critical decision-making in emergency situations, ensuring that patient needs are addressed promptly and appropriately. This rationale underscores the significance of respiratory assessments in patients with breathing difficulties, emphasizing the need for targeted and efficient care delivery.

Correct Answer: A

Rationale: The correct answer is option A) Use a lubricated blunt tip thermometer. When assessing rectal temperature in an adult, using a lubricated blunt tip thermometer is essential to ensure patient comfort and safety. The blunt tip helps prevent injury to the rectal wall, while lubrication facilitates easy and gentle insertion. Option B) Insert the thermometer 2 to 3 inches into the rectum is incorrect as the thermometer should only be inserted about 1 inch into the rectum for an accurate reading in adults. Inserting it too far can cause discomfort and potential injury. Option C) Leaving the thermometer in place up to 8 minutes if the patient is febrile is incorrect as rectal temperature readings typically stabilize within a minute or two. Prolonged insertion can be uncomfortable for the patient and is unnecessary. Option D) Waiting 2 to 3 minutes if the patient has recently smoked a cigarette is incorrect as this factor does not affect the accuracy of rectal temperature measurement. Smoking may slightly affect oral temperature readings but not rectal temperatures. Educationally, it's important for nurses to understand the correct technique for assessing rectal temperature to ensure accurate readings and patient comfort. Proper use of equipment, like a lubricated blunt tip thermometer, and following correct insertion guidelines are crucial aspects of providing safe and effective patient care.

Correct Answer: B

Rationale: The correct answer is B) An increased respiratory rate and a shallower inspiratory phase are expected findings in aging adults. This is because as individuals age, their respiratory muscles weaken and lung elasticity decreases, leading to a shallower breathing pattern and an increased respiratory rate to maintain adequate oxygenation. Option A is incorrect because while blood vessel stiffness may affect blood pressure measurements, it does not directly impact the palpation of the pulse. Option C is incorrect as a decreased pulse pressure typically results from increased arterial stiffness, not changes in both systolic and diastolic pressures. Option D is incorrect because aging does not necessarily make a person more prone to developing a fever; rather, it may affect the body's ability to regulate temperature efficiently. In an educational context, it is essential for nurses and healthcare providers to understand the physiological changes that occur with aging to accurately assess vital signs in older adults. By recognizing expected findings like changes in respiratory rate and depth, healthcare professionals can provide appropriate care and interventions tailored to the needs of this population.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Is caused by increased sebum production. Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells. During puberty, hormonal changes can lead to an increase in sebum production, which can contribute to the development of acne. By understanding this connection, the 13-year-old girl can better grasp the underlying cause of her acne and make informed decisions about her skincare routine and treatment options. Option A) Is contagious, is incorrect because acne is not a contagious condition. It is not spread through touch or sharing items like towels or makeup. Option B) Has no known cause, is incorrect because we do know that acne is primarily caused by factors like hormonal changes, genetics, and increased sebum production, as mentioned above. Option D) Has been found to be related to poor hygiene, is incorrect because while good hygiene practices can help prevent acne, poor hygiene alone does not directly cause acne. It is more about the factors mentioned earlier like hormonal changes and sebum production. This question provides valuable information for the 13-year-old girl about the physiological basis of acne, empowering her to take control of her skincare regimen and make informed choices about managing her condition. Understanding the cause of acne can also help dispel common myths and misconceptions surrounding this common skin issue.