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A nurse is preparing a bowel training programfor a patient. Which actions will the nurse take? (Select all that apply.)
- A. Record times when the patient is incontinent.
- B. Help the patient to the toilet at the designated time.
- C. Lean backward on the hips while sitting on the toilet.
- D. Maintain normal exercise within the patient’s physical ability.
Correct Answer: A
Rationale: The correct answer is A. Recording times when the patient is incontinent is crucial in identifying patterns and establishing a structured bowel training program. This data helps in determining the optimal timing for toileting. Choices B, C, and D are incorrect. Choice B is not specific to bowel training and may not address the patient's individual needs. Choice C is not a recommended posture for effective bowel elimination. Choice D, while important for overall health, is not directly related to bowel training.
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You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment?
- A. Is she able to tell her family of negative test results?
- B. Does she have a sense of peace of mind and a purpose to her life?
- C. Can she let go of her husband so he can make a new life?
- D. Does she need time and space to bargain with God for a cure?
Correct Answer: B
Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty.
Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.
A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patients nutritional needs should be met by what method?
- A. Total parenteral nutrition (TPN)
- B. Provision of a low-residue diet
- C. Semisolid food with thick liquids
- D. Minced foods and a fluid restriction
Correct Answer: C
Rationale: The correct answer is C: Semisolid food with thick liquids. Patients with Parkinson's disease often have dysphagia, leading to aspiration and respiratory complications. Semisolid food with thick liquids helps prevent aspiration and promotes safer swallowing. TPN (A) is not necessary for meeting nutritional needs unless the patient cannot tolerate oral intake. A low-residue diet (B) may not address the specific swallowing issues in Parkinson's disease. Minced foods and fluid restriction (D) may not provide adequate nutrition and hydration.
A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action?
- A. Instill the medication in the conjunctival sac.
- B. Maintain a supine position for 10 minutes after administration.
- C. Keep the eyes closed for 1 to 2 minutes after administration.
- D. Apply the medication evenly to the sclera
Correct Answer: A
Rationale: The correct answer is A because instilling the medication in the conjunctival sac allows for direct absorption into the eye tissues. This method ensures that the medication reaches the target area for treating glaucoma effectively. Maintaining a supine position (choice B) or keeping the eyes closed (choice C) after administration does not enhance absorption and may lead to wasted medication. Applying the medication to the sclera (choice D) is incorrect as it does not target the specific area needed for treating glaucoma.
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
- A. Administer antidiarrheal medications on a scheduled basis, as ordered.
- B. Encourage the patient to eat three balanced meals and a snack at bedtime.
- C. Increase the patients oral fluid intake.
- D. Encourage the patient to increase his or her activity level.
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
- A. Abdominal palpation
- B. Venous sample of blood
- C. Checking deep tendon reflexes
- D. Auscultation of the heart and lungs
Correct Answer: A
Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (C), auscultation of the heart and lungs (D), and venous sample of blood (B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.