Which is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain?

"Did someone come to the hospital with you?"

"When did your chest pain begin?"

"Did your family doctor tell you to come to the hospital?"

"Do you have a family history of heart disease?"

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.

Choice B reason: This is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is relevant, open-ended, and comprehensive. The nurse should ask questions that are related to the patient's health status, needs, or goals, and that elicit more information from the patient. This question allows the patient to describe the onset, duration, and frequency of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.

Choice C reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.

Choice D reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because utilizing a no-rinse shampoo cap is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A no-rinse shampoo cap is a disposable cap that contains a pre-moistened shampoo and conditioner. It can be heated in a microwave and applied to the patient's head without the need for water or rinsing. It can clean and condition the patient's hair without causing any discomfort or movement of the affected shoulder.

Choice B reason: This is an incorrect choice because using a handheld shower sprayer is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A handheld shower sprayer is a device that attaches to a faucet and allows the user to direct the water flow. It can be difficult and painful for the patient to use or hold the sprayer with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice C reason: This is an incorrect choice because having the patient lean over the wash basin is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A wash basin is a bowl or sink that contains water and soap for washing. It can be uncomfortable and risky for the patient to lean over the basin with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice D reason: This is an incorrect choice because having the patient lean back into the sink is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A sink is a basin with a faucet that provides water for washing. It can be uncomfortable and risky for the patient to lean back into the sink with the affected shoulder, and it can also wet the surgical dressing or incision site.

A. Unilateral neglect related to brain tissue damage after right-sided stroke B. Ineffective denial related to inability to accept paralysis of left arm and leg C. Deficient knowledge related to presence of paralyzed left arm and leg D. Noncompliance related to inability to follow directions to use left arm and leg

Correct Answer is A

Explanation

Choice A reason: This is correct. Unilateral neglect is a condition where the patient fails to attend to or respond to stimuli on the opposite side of the brain lesion. It can affect the patient's perception, attention, memory, and motor function. It can also impair the patient's safety, self-care, and quality of life. The patient may not recognize the existence of the paralyzed limbs, ignore them, or deny their ownership.

Choice B reason: This is incorrect. Ineffective denial is a condition where the patient consciously or unconsciously refuses to acknowledge the reality of a situation that is too threatening or overwhelming. It can interfere with the patient's coping and adaptation. The patient may reject the diagnosis, prognosis, or treatment of the condition. However, this is not the case for the patient with unilateral neglect, who is not aware of the paralysis, rather than refusing to accept it.

Choice C reason: This is incorrect. Deficient knowledge is a condition where the patient lacks or misinterprets information about a topic related to health or illness. It can affect the patient's decision-making, compliance, and outcomes. The patient may have inaccurate or incomplete understanding of the causes, consequences, or management of the condition. However, this is not the main problem for the patient with unilateral neglect, who is not able to process or attend to the information, rather than lacking it.

Choice D reason: This is incorrect. Noncompliance is a condition where the patient does not or is unable to follow the prescribed or agreed-upon plan of care. It can result from various factors, such as lack of motivation, resources, support, or understanding. The patient may not adhere to the recommendations, instructions, or goals of the treatment. However, this is not the primary issue for the patient with unilateral neglect, who is not capable of performing the tasks, rather than unwilling to do so.

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Which is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery?

Correct Answer is A

Explanation

Which is the most appropriate nursing diagnosis for a patient who has a severe right-sided stroke with left-sided hemiplegia? The patient uses the right extremities well but does not realize that the left arm and leg even exist.

Correct Answer is A

Explanation

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