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A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?
- A. Applying a protective eye shield at night
- B. Chewing on the affected side to prevent unilateral neglect
- C. Avoiding the use of analgesics whenever possible
- D. Avoiding brushing the teeth
Correct Answer: A
Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications.
Summary of Incorrect Choices:
B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial.
C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms.
D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.
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A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.
- A. 1800
- B. 450
- C. 900
- D. 90
Correct Answer: C
Rationale: The correct answer is C (900 mL) because the weight of 900 g corresponds to a blood loss of the same amount in milliliters. Blood density is close to that of water, so 1 g ≈ 1 mL. Therefore, a blood-soaked peripad weighing 900 g indicates a blood loss of 900 mL. Choice A (1800 mL) is incorrect as it doubles the weight instead of converting it to milliliters. Choice B (450 mL) is incorrect as it halves the weight. Choice D (90 mL) is incorrect as it divides the weight by 10, which is too small for the blood loss indicated.
The nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel (NAP)?
- A. Performing the first postoperative pouch change
- B. Maintaining a nasogastric tube
- C. Administering an enema
- D. Digitally removing stool
Correct Answer: C
Rationale: Correct Answer: C - Administering an enema
Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making.
Summary of other choices:
A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse.
B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse.
D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
- A. You know, you are getting older now and we change as we get older.
- B. The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry.
- C. There is a gradual thickening of the lens of the eye and it can limit the eyes ability for accommodation.
- D. The eye gets shorter, back to front, as we age and it changes how we see things.
Correct Answer: C
Rationale: The correct answer is C because it accurately explains the physiological change in the eye that leads to the need for bifocals. As individuals age, there is a gradual thickening of the lens of the eye, which affects the eye's ability to accommodate for near vision. This thickening makes it harder for the eye to focus on close objects, necessitating the use of bifocals to correct this near vision issue.
Choices A, B, and D are incorrect because they do not provide a scientifically accurate explanation for the need for bifocals in older individuals. Option A is dismissive and does not address the specific change in the eye that leads to the need for bifocals. Option B implies aging as a general concept without specifying the relevant change in the eye. Option D incorrectly states that the eye gets shorter as we age, which is not the reason for needing bifocals.
A nurse is reviewing results from a urine specimen.What will the nurse expect to see in a patient with a urinary tract infection?
- A. Casts
- B. Protein
- C. Crystals
- D. Bacteria
Correct Answer: D
Rationale: The correct answer is D: Bacteria. In a patient with a urinary tract infection (UTI), bacteria are typically present in the urine due to the infection of the urinary system. Bacteria may be detected through urine culture or microscopic examination.
A: Casts are not typically associated with UTIs but can indicate kidney disease.
B: Protein in the urine can indicate kidney damage or other issues, not specific to UTIs.
C: Crystals in the urine can be normal or indicate specific conditions, but they are not specific to UTIs.
In summary, the presence of bacteria in the urine is a key indicator of a UTI, while the other choices are more indicative of different conditions or factors.
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
- A. Utilize a pressure-reducing mattress.
- B. Limit the patients physical activity.
- C. Apply antibiotic ointment to dependent skin surfaces.
- D. Avoid contact with synthetic fabrics.
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.