during an assessment the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck which action by the during an assessment the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck which action by the
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1. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?

Correct answer: Ask the patient about the item and its significance.

Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet’s meaning to the patient. Asking the patient to lock the item with other valuables in the hospital’s safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient’s cultural health practices.

2. Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)

Correct answer: Oxygen saturation

Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.

3. Which of the following measures would be appropriate for a nurse to teach the parent of a nine-month-old infant about diaper dermatitis?

Correct answer: Discontinue a new food that was added to the infant's diet just prior to the rash

Rationale: Diaper dermatitis can be caused by various factors, one of which includes introducing new foods to the infant's diet. Discontinuing the new food that was added just before the rash can help identify and eliminate the potential cause. Options A and C are not directly related to addressing the cause of diaper dermatitis. While using cloth diapers rinsed in bleach may be a preventive measure for diaper dermatitis, it is not addressing a specific cause. Option B, advising against using occlusive ointments on the rash, may actually be beneficial in managing diaper dermatitis, but it does not address the cause of the condition.

4. Which of the following is an example of non-reversible dementia?

Correct answer: Pick's disease

Rationale: Non-reversible dementia refers to a condition where individuals experience permanent and often progressive cognitive decline. Pick's disease is a type of non-reversible dementia characterized by changes in personality, behavior, and language difficulties. Syphilis (Choice B) is a reversible cause of dementia that can be treated with antibiotics. Encephalopathy (Choice C) is a broad term for brain dysfunction that can be reversible or irreversible depending on the cause. Hyperthyroidism (Choice D) can lead to cognitive impairment but is reversible with appropriate treatment. Therefore, Pick's disease is the correct example of non-reversible dementia among the options provided.

5. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?

Correct answer: The patients white blood cell (WBC) count is 9000/L

Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

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