Nokea
A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25” to 0.5”
- B. 2” to 4”
- C. 1” to 1.5”
- D. 5” to 7”
Correct Answer: C
Rationale: The correct answer is C: 1” to 1.5”. When irrigating a colostomy, the client should insert the lubricated catheter about 1” to 1.5” into the stoma. This depth allows for effective irrigation of the colon without causing discomfort or damage. Inserting the catheter too shallow (choice A) may not reach the colon, while inserting it too deep (choices B and D) can cause injury or perforation. Therefore, the optimal depth of 1” to 1.5” ensures proper irrigation while minimizing risks of complications.
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A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:
- A. Provide clear liquids only until the patient can swallow solid foods.
- B. Have the patient swallow twice after each bite
- C. Place food on the unaffected side of the patient’s mouth
- D. Check if the patient’s mouth for pocketing of food
Correct Answer: A
Rationale: The correct answer is A because providing clear liquids only until the patient can swallow solid foods is not a recommended nursing intervention to prevent aspiration. Clear liquids do not require the same level of swallowing coordination as solid foods, so it may not help improve swallowing ability.
B: Having the patient swallow twice after each bite can help clear the throat and reduce the risk of aspiration.
C: Placing food on the unaffected side of the mouth can help direct the food towards the stronger side for swallowing.
D: Checking the patient's mouth for pocketing of food is important to ensure that food is not being retained in the mouth, which could lead to aspiration.
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue).
Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.
A patient asks the nurse what her diagnosis of heart failure means. Which of the ff. is the nurse’s best response?
- A. “Your heart briefly stops.”
- B. “Your heart has an area of muscle that is dead.”
- C. “Your heart is pumping to much blood.”
- D. “Your heart is not an efficient pump.”
Correct Answer: D
Rationale: The correct answer is D: “Your heart is not an efficient pump.” This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention.
Explanation:
1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly.
2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart.
3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.
Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: The correct answer is A: Provide positive feedback when he uses the word correctly. In individuals with expressive aphasia, positive reinforcement helps improve communication skills. Praising Mr. Reyea when he uses words correctly encourages continued effort and boosts confidence. This approach motivates him to communicate more despite his challenges.
Summary of other choices:
B: Waiting indefinitely for Mr. Reyea to verbally state needs is not practical and may lead to frustration.
C: Suggesting permanent help at home assumes the disability cannot improve, which is not necessarily true for expressive aphasia.
D: Helping the family to accept Mr. Reyea's inability to communicate verbally may hinder his progress and limit his social interactions.
A client in the final stages of terminal cancer tells the nurse: “I wish I could be just be allowed to die. I’m tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the best nurse’s best response?
- A. “Would you like to talk to a psychologist about your thoughts and feelings?”
- B. “Would you like to talk to your minister about the significance of death?”
- C. “Would you like to meet with your family and your physician about this matter?”
- D. “I know you are tired of fighting this illness, but death will come in due time.”
Correct Answer: C
Rationale: The correct response is C: “Would you like to meet with your family and your physician about this matter?”
Rationale:
1. Involving the family and physician ensures a collaborative decision-making process.
2. It respects the client's autonomy and involves them in the decision-making process.
3. It promotes open communication and support from loved ones.
4. It addresses the client's concerns about continuing treatment based on family wishes.
Summary:
A: Refers to psychological support, but the client's primary concern is medical treatment decisions.
B: Involves religious support, which may not align with the client's beliefs or address the medical decision.
D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.