Nokea
A clinic nurse is providing patient education prior to a patients scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this?
- A. The patient is not listening effectively.
- B. The patient is noncompliant with the plan of care.
- C. The patient may have a low intelligence quotient or a cognitive deficit.
- D. The patient has not achieved the desired learning outcomes.
Correct Answer: D
Rationale: The correct answer is D. The plausible conclusion the nurse should draw is that the patient has not achieved the desired learning outcomes.
1. The patient's repeated questions indicate a lack of understanding despite the nurse's teaching efforts.
2. This suggests that the patient has not grasped the information provided.
3. It does not necessarily mean the patient is not listening effectively, noncompliant, or has low intelligence.
4. The focus should be on reassessing the teaching methods and providing additional support to help the patient achieve the desired learning outcomes.
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A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
- A. Administer antidiarrheal medications on a scheduled basis, as ordered.
- B. Encourage the patient to eat three balanced meals and a snack at bedtime.
- C. Increase the patients oral fluid intake.
- D. Encourage the patient to increase his or her activity level.
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurses best response?
- A. I can only imagine how you feel. Would you like to talk about it?
- B. Lets find a quiet spot and Ill teach you a few coping strategies.
- C. Thats the same way that most patients who have a chronic illness feel.
- D. Do you think that maybe you could be managing things more efficiently?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship.
Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.
When assessing patient with nutritional needs, which patients will require follow-up from the nurse?(Select all that apply.)
- A. A patient with infection taking tetracycline with milk
- B. A patient with irritable bowel syndrome increasing fiber
- C. A patient with diverticulitis following a high-fiber diet daily
- D. A patient with an enteral feeding and 500 mL of gastric residual
Correct Answer: A
Rationale: The correct answer is A: A patient with infection taking tetracycline with milk. This is because tetracycline binds with the calcium in milk, reducing its absorption and effectiveness. The nurse should follow up to ensure the patient is not compromising the treatment.
Choices B and C are incorrect because increasing fiber for irritable bowel syndrome and following a high-fiber diet for diverticulitis are appropriate interventions that do not require immediate follow-up.
Choice D is incorrect because it is a routine part of managing enteral feedings to monitor gastric residuals, and does not necessarily require immediate follow-up unless there are specific concerns.
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect?
- A. Cytotoxic reaction due to contact with the powder in the gloves
- B. Immune complex reaction due to contact with anesthetic gases
- C. Anaphylaxis due to a latex allergy
- D. Delayed reaction due to exposure to cleaning products
Correct Answer: C
Rationale: The correct answer is C: Anaphylaxis due to a latex allergy. Anaphylaxis is a severe allergic reaction that can be triggered by exposure to latex products such as gloves in the operating room. The symptoms of swelling of the eyes and difficulty breathing are classic signs of anaphylaxis.
Rationale:
1. Swelling of the eyes and difficulty breathing are hallmark symptoms of anaphylaxis.
2. Latex is a common allergen that can cause severe allergic reactions like anaphylaxis.
3. The student's symptoms are occurring shortly after entering the operating room, suggesting an acute allergic reaction.
4. The other choices (A, B, D) do not align with the symptoms presented and are less likely in this scenario.
The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the patient?
- A. Ensure adequate lighting in the patients room.
- B. Provide a dimly lit room to aid vision by limiting contrast.
- C. Carefully point out color differences for the patient.
- D. Carefully point out fine details for the patient.
Correct Answer: A
Rationale: Rationale: The correct answer is A because rods are responsible for vision in low light conditions. By ensuring adequate lighting in the patient's room, the nurse can optimize the patient's visual acuity. This will help the patient navigate their environment more safely.
Summary:
- B is incorrect because dim lighting would further limit the patient's already compromised vision.
- C is incorrect as the patient's ability to perceive color may not be affected by rod dysfunction.
- D is incorrect as the patient may struggle to see fine details due to rod impairment.