Nokea
A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
- A. Diarrhea/Constipation related to altered bowel patterns.
- B. Knowledge Deficit related to disease process and diagnostic procedure.
- C. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea.
- D. Anxiety related to unknown outcomes and perceived threats to body integrity.
Correct Answer: D
Rationale: The patient's anger and threat to leave indicate significant anxiety, which must be addressed before proceeding with education or further assessment.
You may also like to solve these questions
What should be included in Mr. Ross’s plan of care during radiation therapy if he complains of weakness and lethargy?
- A. Encouraging him to rest more than usual
- B. Monitoring his intake and output
- C. Helping him to accept his condition
- D. Checking his blood pressure daily
Correct Answer: A
Rationale: Rest conserves energy and aids recovery during radiation therapy.
A 20-year-old patient with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support?
- A. Irreversible cessation of all brain functions.
- B. Absence of brainstem reflexes.
- C. No spontaneous respirations.
- D. Fear of pain
Correct Answer: B
Rationale: Brain death is confirmed when there is irreversible cessation of all brain functions, absence of brainstem reflexes, and no spontaneous respirations, meeting legal and medical criteria for death.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.
To communicate with a patient who does not speak the dominant language, the nurse should
- A. Speak slowly and enunciate clearly in a slightly louder voice.
- B. Use gestures and pantomime words while verbalizing specific words.
- C. Use family members rather than strangers as interpreters to increase the patient’s feeling of comfort.
- D. Use a dictionary or phrase books that translate from both the nurse’s language and the patient’s language.
Correct Answer: A
Rationale: Speaking slowly, using gestures, and utilizing translation tools facilitate effective communication. Using family members as interpreters can introduce bias and inaccuracies.
Priority Decision: When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next?
- A. Note this information in the patient's record as hay fever and food allergies.
- B. Place an allergy alert wristband that identifies the specific allergies on the patient.
- C. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.
- D. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.
Correct Answer: C
Rationale: Understanding the nature and severity of allergies helps in planning appropriate perioperative care and avoiding potential allergens.