Nokea
A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
- A. Evaluate the patients milk production.
- B. Palpate the area for a breast mass.
- C. Assess the patients knowledge of breast cancer.
- D. Assure the patient that this likely an age-related change.
Correct Answer: B
Rationale: The correct answer is B. Palpating the area for a breast mass is the most appropriate assessment in this scenario as dimpling of the breast can be a sign of underlying breast abnormalities such as a mass or tumor. By palpating the area, the nurse can determine if there is a lump or any other irregularity that may require further investigation.
Choice A is incorrect because evaluating the patient's milk production is not relevant to the presenting symptom of breast dimpling.
Choice C is incorrect as assessing the patient's knowledge of breast cancer does not address the immediate need for a physical assessment of the breast dimpling.
Choice D is incorrect because assuming that the dimpling is just an age-related change without further assessment could delay potential diagnosis and treatment of a serious condition.
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A nurse is teaching the staff about informatics.Which information from the staff indicates the nurse needs to follow up?
- A. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.
- B. A nurse needs to know how to find, evaluate, and use information effectively.
- C. If a nurse has computer competency, the nurse is competent in informatics
- D. Nursing informatics is a recognized specialty area of nursing practice.
Correct Answer: C
Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes.
A: This is a correct statement about informatics proficiency.
B: This is also a correct statement about the skills needed for informatics.
D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up.
In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.
A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’sfirstpriorityin caring for this patient?
- A. Turn the patient on the right side to alleviate pressure on the left kidney.
- B. Encourage the patient to increase fluid intake to flush the obstruction.
- C. Monitor the patient for fever, rash, and difficulty breathing.
- D. Administer narcotic medications to the patient for pain.
Correct Answer: C
Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows:
1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial.
2. Rash can indicate an allergic reaction to the contrast dye used in the procedure.
3. Difficulty breathing may signal a severe reaction or complications.
Summary:
A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications.
B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications.
D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
- A. Aggressively continuing to fight the disease process
- B. Moving the patient to a long-term care facility when it becomes necessary
- C. Including the children in planning their fathers care
- D. Supporting the patients and familys values and choices
Correct Answer: D
Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.
The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying?
- A. Depression
- B. Denial
- C. Anger
- D. Resignation .
Correct Answer: A
Rationale: The correct answer is A: Depression. In the context of the stages of death and dying proposed by Elisabeth Kübler-Ross, a patient exhibiting signs of loss, grief, and intense sadness is likely in the depression stage. This stage involves feelings of hopelessness, despair, and sorrow as the patient comes to terms with the reality of their situation. Denial (choice B) is characterized by a refusal to accept the diagnosis, anger (choice C) involves feelings of resentment and frustration, and resignation (choice D) signifies a sense of acceptance and peace. In this scenario, the patient's emotional state aligns most closely with depression, indicating a deep sense of sadness and mourning.
A nurse is assisting a patient in making dietarychoices that promote healthy bowel elimination. Which menu option should the nurse recommend?
- A. Broccoli and cheese soup with potato bread
- B. Turkey and mashed potatoes with brown gravy
- C. Grape and walnut chicken salad sandwich on whole wheat bread
- D. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing
Correct Answer: C
Rationale: The correct answer is C because it includes fiber-rich whole wheat bread, grapes, and walnuts which promote healthy bowel elimination. Whole wheat bread and fruits provide dietary fiber that aids in digestion and prevents constipation. Walnuts are high in omega-3 fatty acids which can also help with bowel regularity.
Option A (Broccoli and cheese soup with potato bread) lacks fiber and may cause constipation due to the low fiber content. Option B (Turkey and mashed potatoes with brown gravy) may be low in fiber and high in fat, which can slow down digestion. Option D (Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing) is a healthier choice but may lack sufficient fiber for promoting healthy bowel elimination compared to option C.