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A nurse is caring for four patients; three are toddlers and one is a preschooler. Which represents the major stressor of hospitalization for these four patients?
- A. Separation anxiety
- B. Loss of control
- C. Fear of bodily injury
- D. Fear of pain
Correct Answer: A
Rationale: Separation anxiety is the major stressor of hospitalization for these young patients. Toddlers and preschoolers are at a critical stage of development where they are developing close attachments to their primary caregivers. Being separated from their parents or primary caregivers when admitted to the hospital can lead to feelings of fear, distress, and insecurity. This separation can significantly impact their emotional well-being and overall hospital experience. Loss of control, fear of bodily injury, and fear of pain are also stressors associated with hospitalization, but separation anxiety is the primary concern for these young patients due to their developmental stage.
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An adult has been stung by a bee and is in anaphylactic shock. An epinephrine (adrenaline) injection has been given. The nurse would expect which the following if the injection has been effective?
- A. The client's breathing will become easier
- B. The client's blood pressure will decrease
- C. There will be an increase in angiodema
- D. There will be a decrease in the client's level of consciousness
Correct Answer: A
Rationale: An epinephrine (adrenaline) injection is the first-line treatment for anaphylaxis, as it helps to relax the muscles in the airway and improve breathing. This results in the client's breathing becoming easier. Epinephrine also acts to increase blood pressure, while angioedema (swelling) and a decreased level of consciousness are not expected effects of an effective epinephrine injection.
The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born preterm." This information should be recorded under which of the following headings?
- A. Past history
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct Answer: A
Rationale: The information given by the mother about having a difficult delivery and her baby being born preterm is considered part of the past medical history. Past medical history includes previous medical conditions, surgeries, hospitalizations, and significant events related to the patient's health before the current encounter. This information helps healthcare providers understand the patient's background and any potential risks or complications relevant to their current health condition.
A 70-year old male diagnosed with BPH (benign prostatic hyperplasia) asks the nurse about his disease. The best response would be:
- A. "It an be caused by chronic infection of the urinary tract."
- B. "It was caused by your chronic cigarette smoking."
- C. "As you age, hormonal imbalances are the more likey cause of your disease."
- D. "Chronic obstruction of the bladder due to stone can cause BPH."
Correct Answer: C
Rationale: Option C, "As you age, hormonal imbalances are the more likely cause of your disease," is the best response. Benign prostatic hyperplasia (BPH) is a common condition in aging men characterized by an enlarged prostate gland. It is predominantly influenced by hormonal changes, specifically the imbalance between levels of testosterone and estrogen as men age. This hormonal imbalance leads to the proliferation of prostatic tissue and subsequent enlargement of the prostate gland, causing symptoms such as urinary frequency, urgency, weak stream, and difficulty emptying the bladder. Chronic infection of the urinary tract (Option A) and chronic cigarette smoking (Option B) are not the primary causes of BPH. While chronic obstruction of the bladder due to a stone (Option D) can cause similar symptoms to BPH, the underlying etiology of BPH is related to hormonal changes associated with aging.
The parents of a newborn who has just died decide they want to hold their deceased infant. What is the most appropriate nursing intervention?
- A. Explain gently that this is no longer possible.
- B. Encourage parents to accept the loss of their newborn.
- C. Offer to take a photograph of their newborn because they cannot hold newborn.
- D. Get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can hold their deceased infant.
Correct Answer: D
Rationale: The most appropriate nursing intervention in this situation would be to get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can hold their deceased infant. This is known as a "cold cuddle" technique, where the infant is gently rewarmed for a short period of time to allow the parents to hold and say goodbye to their baby. This practice has been shown to help parents in the grieving process and is a compassionate way to support them during this difficult time. It allows the parents to have a physical connection with their child and provides them with some closure and the opportunity to create lasting memories.
When the LPN is assisting the patient to use an incentive spirometer, which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer?
- A. Taking two normal breaths before use.
- B. Sitting upright before use.
- C. Inhaling deeply to reach target.
- D. Exhaling deeply to reach target.
Correct Answer: D
Rationale: When using an incentive spirometer, the patient should inhale deeply to reach the target volume indicated by the marker. Exhaling deeply does not achieve the objective of the incentive spirometer, which is to encourage deep inhalation. If the patient exhales deeply to reach the target, further teaching and clarification about the proper technique of using the spirometer are needed. The correct technique involves inhaling deeply to expand the lungs and help improve lung function.