Nokea
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
- A. Herpes simplex
- B. HIV
- C. Spina bifida
- D. Hypogammaglobulinemia
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems.
Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies.
Choice B: HIV weakens the immune system but is not specifically associated with latex allergies.
Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.
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The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the patient?
- A. Ensure adequate lighting in the patients room.
- B. Provide a dimly lit room to aid vision by limiting contrast.
- C. Carefully point out color differences for the patient.
- D. Carefully point out fine details for the patient.
Correct Answer: A
Rationale: Rationale: The correct answer is A because rods are responsible for vision in low light conditions. By ensuring adequate lighting in the patient's room, the nurse can optimize the patient's visual acuity. This will help the patient navigate their environment more safely.
Summary:
- B is incorrect because dim lighting would further limit the patient's already compromised vision.
- C is incorrect as the patient's ability to perceive color may not be affected by rod dysfunction.
- D is incorrect as the patient may struggle to see fine details due to rod impairment.
A patient develops a foodborne disease fromEscherichiacoli. When taking a health history, which food item will the nursemostlikely find the patient ingested?
- A. Improperly home-canned food
- B. Undercooked ground beef
- C. Soft cheese
- D. Custard
Correct Answer: B
Rationale: The correct answer is B: Undercooked ground beef. Escherichia coli is commonly found in undercooked ground beef, especially if it is contaminated during processing. Ground beef must be cooked to a safe internal temperature to kill any harmful bacteria. Improperly home-canned food (choice A) can also cause foodborne illnesses, but E. coli is more commonly associated with undercooked ground beef. Soft cheese (choice C) is often linked to Listeria contamination, not E. coli. Custard (choice D) is a less likely source of E. coli compared to undercooked ground beef.
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
- A. Ask the patient to repeat what was said in order to evaluate understanding.
- B. Stand directly in front of the patient to facilitate lip reading.
- C. Reduce environmental noise and distractions before communicating.
- D. Raise the voice to project sound at a higher frequency.
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication.
The other choices are incorrect because:
A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication.
B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication.
D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.
A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
- A. Not until the drain is removed
- B. On the second postoperative day
- C. Now, if you wash gently with soap and water
- D. Seven days after your surgery
Correct Answer: A
Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications.
Summary:
B: On the second postoperative day - Too early, the drain needs to be removed first.
C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering.
D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.
A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient?
- A. Sit or stand in front of the patient when speaking.
- B. Use exaggerated lip and mouth movements when talking.
- C. Stand in front of a light or window when speaking.
- D. Say the patients name loudly before starting to talk.
Correct Answer: A
Rationale: The correct answer is A: Sit or stand in front of the patient when speaking. This choice is correct because it allows the patient with otosclerosis to directly see the nurse's face and lip movements, aiding in lip-reading and understanding speech. Sitting or standing in front of the patient also ensures better eye contact and reduces background noise interference.
Choice B is incorrect because exaggerated lip and mouth movements may distort speech and make it harder for the patient to understand. Choice C is incorrect because standing in front of a light or window can create glare and make it difficult for the patient to see the nurse's face clearly. Choice D is incorrect because saying the patient's name loudly before starting to talk does not directly address the communication needs of a patient with otosclerosis.