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A 25-year-old female patient with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the patient is not receiving treatment for her brain metastases, what is the nurses most appropriate action?
- A. Promoting the patients functional status and ADLs
- B. Ensuring that the patient receives adequate palliative care
- C. Ensuring that the family does not tell the patient that her condition is terminal
- D. Promoting adherence to the prescribed medication regimen
Correct Answer: B
Rationale: The correct answer is B: Ensuring that the patient receives adequate palliative care. Palliative care focuses on improving the quality of life for patients with serious illnesses, including managing symptoms and providing emotional support. In this case, since the patient is not receiving treatment for her brain metastases, palliative care would be most appropriate to help alleviate any pain or discomfort she may be experiencing and provide holistic support for her and her family.
A: Promoting the patient's functional status and ADLs may not be the priority if the patient's prognosis is terminal and she is not receiving treatment for her brain metastases.
C: Ensuring that the family does not tell the patient her condition is terminal goes against ethical principles of honesty and transparency in healthcare.
D: Promoting adherence to the prescribed medication regimen may not be relevant if the patient is not receiving active treatment for her brain metastases.
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A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
- A. Maintenance of good perineal hygiene
- B. Prevention of constipation
- C. Increased fluid intake for 2 weeks postpartum
- D. Performance of pelvic muscle exercises Chapter 58: Breast Cancer: Breast cancer – risks factors, Diagnostic tests and management, Self Breast Exam, Perioperative care: Complications, Rehab, Discharge teaching
Correct Answer: D
Rationale: The correct answer is D, performance of pelvic muscle exercises. Pelvic muscle exercises, also known as Kegel exercises, help strengthen the pelvic floor muscles which support the bladder, uterus, and bowel. By strengthening these muscles, the risk of developing cystocele, rectocele, and uterine prolapse postpartum is reduced. It is a proactive approach to prevent these conditions.
Choice A, maintenance of good perineal hygiene, is important for preventing infections but does not specifically address the risk of pelvic organ prolapse. Choice B, prevention of constipation, is also important but does not directly target the muscle weakness that contributes to prolapse. Choice C, increased fluid intake for 2 weeks postpartum, is not as effective in preventing prolapse as pelvic muscle exercises.
In summary, pelvic muscle exercises are the most appropriate recommendation as they directly address strengthening the muscles that support the pelvic organs, reducing the risk of prolapse postpartum.
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 nurse preceptor is working with a student nurse.Which behavior by the student nurse will require the nurse preceptor to intervene?
- A. Chew gum
- B. Turn off the television.
- C. Speak clearly and loudly
- D. Use at least 14-point print
Correct Answer: B
Rationale: The correct answer is B because turning off the television is necessary for effective learning and communication between the nurse preceptor and student nurse. Watching TV can be distracting and disrespectful during the learning process. Choices A, C, and D are incorrect because chewing gum, speaking clearly and loudly, and using at least 14-point print are behaviors that do not hinder the learning process and can be acceptable in a professional setting.
A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following?
- A. Briefly teaching the patient about normal sexual physiology
- B. Assuring the patient that what he says will be confidential
- C. Asking the patient if he is willing to discuss sexual functioning
- D. Ensuring patient privacy
Correct Answer: D
Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.
Which behaviors indicate the student nurse hasa good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Selectall that apply.)
- A. Writes the patient’s room number and date of birth on a paper for school
- B. Prints/copies material from the patient’s health record for a graded care plan
- C. Reviews assigned patient’s record and another unassigned patient’s record
- D. Gives a change-of-shift report to the oncoming nurse about the patient
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
- Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals.
- A: Writing the patient’s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals.
- B: Printing/copying material from the patient’s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization.
- C: Reviewing assigned patient’s record and another unassigned patient’s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.