While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

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Question 1 of 9

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.

Question 2 of 9

An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?

Correct Answer: D

Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.

Question 3 of 9

Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?

Correct Answer: A

Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow. Incorrect choices: B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties. C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties. D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.

Question 4 of 9

The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

Correct Answer: A

Rationale: The correct answer is A: Diagnosis. The nurse should proceed to the diagnosis step of the nursing process after reviewing the patient's data. In this step, the nurse will analyze the information gathered to identify the patient's health problems and needs. Given the patient's lack of voiding, abnormal kidney function, and decreased oral intake, the nurse needs to determine the underlying issues contributing to these findings. This analysis will guide the nurse in developing a plan of care to address the patient's specific health concerns. Choice B: Planning would be premature without a clear understanding of the patient's health problems, needs, and contributing factors. Choice C: Implementation would involve carrying out interventions without a thorough understanding of the patient's health issues. Choice D: Evaluation comes after the implementation of interventions to assess their effectiveness, which cannot be done without a clear diagnosis.

Question 5 of 9

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Correct Answer: D

Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.

Question 6 of 9

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

Correct Answer: B

Rationale: The correct answer is B: Take a deep breath as the nurse deflates the cuff. This is the correct choice because asking the client to take a deep breath while the cuff is deflated helps prevent aspiration of secretions into the lower airway. When the cuff is deflated, the tracheostomy tube provides a direct pathway for secretions to travel upwards, and taking a deep breath facilitates the movement of secretions out of the trachea. Choice A (Cough as the cuff is being deflated) is incorrect because coughing while the cuff is being deflated can increase the risk of aspiration as secretions may be forced into the lower airway. Choice C (Hold the breath as the cuff is being re-inflated) is incorrect as holding the breath while the cuff is being re-inflated can hinder the clearance of secretions from the trachea. Choice D (Exhale deeply as the nurse re-inflates the cuff) is incorrect

Question 7 of 9

Which of the ff. type of eyedrops does the nurse understand is given to constrict the pupil, permitting aqueous humor to flow around the lens?

Correct Answer: C

Rationale: The correct answer is C: Myotic. Myotic eyedrops constrict the pupil, allowing aqueous humor to flow around the lens. Myotic agents, such as pilocarpine, work by stimulating the sphincter muscle of the iris. Osmotic eyedrops (A) reduce intraocular pressure, mydriatic eyedrops (B) dilate the pupil, and cycloplegic eyedrops (D) paralyze the ciliary muscle to prevent accommodation.

Question 8 of 9

A patient has allergic rhinitis. In planning care for the patient, the nurse understands that if the patient does not remain compliant with the treatment regimen, the patient is at risk for developing which of the following?

Correct Answer: A

Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications. Summary of other choices: B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis. C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis. D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.

Question 9 of 9

Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?

Correct Answer: A

Rationale: The correct answer is A: Muscle weakness. After unilateral adrenalectomy, there is a risk of hyperkalemia due to decreased aldosterone production. Aldosterone helps regulate potassium levels in the body. Muscle weakness is a common symptom of hyperkalemia as high potassium levels can affect muscle function. Diaphoresis, tremors, and constipation are not typically associated with hyperkalemia. Diaphoresis is excessive sweating, tremors are involuntary muscle movements, and constipation is difficulty passing stool. These symptoms are not directly related to potassium imbalance.

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