Which of the following statements is an example of flight of ideas?

Questions 37

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advanced health assessment test bank Questions

Question 1 of 9

Which of the following statements is an example of flight of ideas?

Correct Answer: C

Rationale: The correct answer is C because it demonstrates a rapid succession of loosely associated thoughts, typical of flight of ideas. The statement transitions from discussing a pill to the color red, then red velvet, and finally to a baby's bottom. This rapid and disjointed flow of thoughts is characteristic of flight of ideas, a symptom commonly seen in manic episodes of bipolar disorder. Choices A, B, and D do not exhibit the same level of rapid and tangential thoughts as choice C, making them incorrect.

Question 2 of 9

The nurse is obtaining the health history of an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?

Correct Answer: D

Rationale: Rationale: 1. Current health promotion activities are important to assess the patient's preventive measures. 2. At 87 years old, focusing on current habits can help identify areas for improvement. 3. Obstetrical history is irrelevant as the patient is postmenopausal. 4. Childhood illnesses are less relevant compared to current health status. 5. General health for the past 20 years may not reflect current health behaviors.

Question 3 of 9

The inspection phase of the physical assessment:

Correct Answer: B

Rationale: The correct answer is B because the inspection phase of a physical assessment involves visually examining the patient's body, which can reveal a surprising amount of information. This step is crucial in identifying visible abnormalities, such as skin discoloration, swelling, or asymmetry. It helps in assessing the patient's overall appearance, posture, and body movements. This detailed observation can provide valuable insights into the patient's health status and aid in making an accurate diagnosis. Choice A is incorrect because the inspection phase actually provides significant information. Choice C is incorrect as it downplays the importance of thorough observation. Choice D is incorrect because the discomfort level for the expert practitioner is not a defining factor in the inspection phase.

Question 4 of 9

A nurse is caring for a patient with a history of chronic liver disease. The nurse should monitor for which of the following complications?

Correct Answer: B

Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.

Question 5 of 9

A nurse is caring for a patient with a history of chronic asthma. The nurse should prioritize monitoring for which of the following complications?

Correct Answer: C

Rationale: The correct answer is C: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.

Question 6 of 9

Which of the following are considered second-level priority problems?

Correct Answer: C

Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that are important to the patient's health but may not be life-threatening. Abnormal laboratory values fall into this category as they indicate an underlying health issue that needs attention. Low self-esteem (A) and lack of knowledge (B) are typically considered third-level priority problems, as they do not pose an immediate threat to the patient's health. Severely abnormal vital signs (D) are first-level priority problems, as they indicate an acute and potentially life-threatening situation that requires immediate intervention. Therefore, the correct answer is C as it aligns with the definition of second-level priority problems.

Question 7 of 9

A nurse is frequently bothered when a patient does not take the medications as prescribed until the patient speaks with her family. The nurse is so irritated by this behaviour that he often finds it hard to provide appropriate care to this individual. What should the nurse do first in trying to overcome his difficulty?

Correct Answer: B

Rationale: Step 1: Recognize Cultural Sensitivity - Understanding that family inclusion is a cultural practice is crucial as it helps the nurse appreciate the patient's perspective. Step 2: Empathy - Acknowledging the significance of family involvement for the patient shows empathy and respect for their beliefs and values. Step 3: Effective Communication - By recognizing and respecting the cultural practice, the nurse can build a trusting relationship with the patient and her family, leading to better adherence to medication and improved care outcomes. In summary, Option B is correct as it emphasizes cultural competence and patient-centered care. Options A, C, and D are incorrect as they do not address the core issue of cultural understanding and may hinder effective communication and relationship-building with the patient and her family.

Question 8 of 9

During the health assessment, the nurse notes that a patient is anxious and worried about upcoming surgery. What is the nurse's first priority in this situation?

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's emotional state and provide reassurance. The first priority is to address the patient's anxiety and worry, as this can impact their overall well-being and ability to cope with the upcoming surgery. By assessing the emotional state, the nurse can understand the patient's concerns and provide appropriate support and reassurance. Discussing the risks and benefits (choice B) may be important but not the immediate priority. Encouraging relaxation (choice C) may not address the underlying anxiety. Calling the surgeon (choice D) is not necessary at this point as the nurse should first focus on the patient's emotional needs.

Question 9 of 9

The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs audibly. Which of the following statements does the nurse know is most accurate, considering the concept of communication?

Correct Answer: B

Rationale: The correct answer is B because the woman's nonverbal cues (looking nervously at her hands, sighing audibly) indicate potential anxiety or stress. The nurse should acknowledge these cues and explore her feelings further to provide appropriate support. Option A is incorrect as it does not address the woman's nonverbal cues. Option C is incorrect as it assumes the woman is not genuinely excited about the pregnancy. Option D is incorrect as it overlooks the woman's nonverbal cues and does not address her potential emotional needs.

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