A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information?
Are you allergic to any other drugs?
How often have you received penicillin?
Describe what happens to you when you take penicillin
I’ll write your allergy on your chart so you won’t receive any penicillin
The Correct Answer is C
Choice A reason: Asking about other drug allergies is relevant but secondary to understanding the penicillin allergy’s nature. Without clarifying the reaction’s severity (e.g., anaphylaxis vs. rash), the nurse cannot fully assess the risk, making this a less immediate response.
Choice B reason: Asking about the frequency of penicillin use does not address the nature or severity of the allergic reaction. This information is irrelevant to managing the allergy and ensuring patient safety, making it an inappropriate initial response.
Choice C reason: Asking the patient to describe their reaction to penicillin clarifies the type and severity of the allergy (e.g., rash, anaphylaxis). This informs safe medication administration and prevents adverse reactions, making it the most critical and appropriate response.
Choice D reason: Documenting the allergy is necessary but premature without understanding the reaction’s specifics. Assuming the allergy without verification could lead to incomplete charting or mismanagement, making this a less priority response compared to gathering details.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cranial Nerve V (trigeminal) controls facial sensation and chewing muscles. It has no role in hearing, which is tested by the whispered voice test, making this an incorrect choice for assessing auditory function.
Choice B reason: Cranial Nerve II (optic) is responsible for vision, not hearing. The whispered voice test evaluates auditory acuity, which is unrelated to visual function, making this an incorrect cranial nerve for the assessment.
Choice C reason: Cranial Nerve VIII (vestibulocochlear) mediates hearing and balance. The whispered voice test assesses the cochlear branch’s ability to transmit sound, making this the correct cranial nerve evaluated by this hearing test.
Choice D reason: Cranial Nerve IV (trochlear) controls the superior oblique eye muscle, affecting eye movement. It is unrelated to hearing, which the whispered voice test assesses, making this an incorrect choice for the described evaluation.
Correct Answer is B
Explanation
Choice A reason: Writing a series of numbers tests attention or working memory, not recent memory recall. Recalling words after a delay specifically assesses short-term memory, which is more relevant for a 70-year-old, so this is not the best method.
Choice B reason: Asking a patient to recall four words after 10 minutes directly tests recent memory, a key cognitive function in older adults. This method is standard in assessments like the Mini-Mental State Exam, making it the best choice for evaluating memory.
Choice C reason: Verifying information like a mother’s maiden name tests long-term memory, not recent recall. Recent memory involves retaining new information, so recalling words after a delay is more appropriate, making this incorrect.
Choice D reason: Naming past presidents relies on long-term memory and general knowledge, not recent memory. Recalling newly learned words after 10 minutes better assesses short-term memory, so this is not the best approach for recent memory.
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