Nokea
A 36-year-old man is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not interact with the nurse. Which action is most appropriate?
- A. Identify the problem with a nursing diagnosis of impaired communication related to the diagnosis of cancer
- B. Set a patient outcome that the patient will verbalize his concerns about his diagnosis
- C. Ask the patient whether he is worried about future sexual functioning
- D. Say, “You seem quiet. Are you feeling concerned about your diagnosis or treatment?”
Correct Answer: D
Rationale: Step-by-step rationale for choosing answer D as correct:
1. Acknowledges patient's withdrawn behavior
2. Demonstrates empathy and concern
3. Open-ended question allows patient to express feelings
4. Encourages patient to communicate concerns
Summary:
- Option A assumes a specific problem without patient input
- Option B focuses on verbalization, not necessarily addressing underlying concerns
- Option C makes assumptions about patient's worries without allowing him to express himself
You may also like to solve these questions
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Check the area after the next menstrual
- C. Squeeze the nipple to check for period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is important because finding a lump in the breast could be a sign of breast cancer, so prompt medical evaluation is crucial. Checking after the next menstrual cycle (B) may delay diagnosis and treatment. Squeezing the nipple (C) can cause harm and is not a reliable method for assessing a lump. Using a heating pad (D) is not recommended as it may mask symptoms and delay proper evaluation. Early detection and intervention are key in improving outcomes for breast cancer.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.
In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?
- A. Etiology
- B. Problem
- C. Defining characteristics
- D. Client need
Correct Answer: A
Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors that lead to the identified problem. In this case, the presence of a large scar over the left side of the face is the underlying cause of the disturbed self-esteem. It directly influences the client's self-perception and self-worth. The problem (B) is the disturbed self-esteem itself, not the scar. Defining characteristics (C) are the signs and symptoms that support the nursing diagnosis. Client need (D) is a broader concept that encompasses the overall needs of the client, whereas etiology specifically focuses on the cause of the problem.
The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
- A. Assisting with activities of daily living
- B. Counseling about respite care options
- C. Teaching range-of-motion exercises
- D. Consulting with a social worker
Correct Answer: B
Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout.
A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain.
C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain.
D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.
The nurse would evaluate that the patient understands what triggers allergic rhinitis by which of the following patient responses?
- A. “Injected medications.”
- B. “Ingested food and medications.”
- C. “Topical creams and ointments.”
- D. “Airborne pollens and molds.”
Correct Answer: D
Rationale: The correct answer is D because airborne pollens and molds are common triggers for allergic rhinitis. Understanding these triggers helps in avoiding exposure and managing symptoms. Choices A, B, and C are incorrect as they do not specifically relate to allergic rhinitis triggers, focusing instead on other forms of medication or topical applications. By understanding airborne triggers, the patient can take appropriate preventive measures.