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A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the
nurse expect?
- A. Distended abdomen
- B. Decreased skin turgor
- C. Increased energy levels
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.
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A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis?
- A. Malleus
- B. Stapes
- C. Incus
- D. Tympanic membrane
Correct Answer: B
Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.
A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses?
- A. Prepare an advance directive.
- B. Designate a most responsible physician (MRP) early in the course of the disease.
- C. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association.
- D. Ensure that witnesses are present when he provides instruction.
Correct Answer: A
Rationale: The correct answer is A: Prepare an advance directive. This allows the patient to document their healthcare preferences in advance, ensuring their wishes are known and honored as the disease progresses. It provides clear instructions for healthcare providers and family members, reducing potential conflicts and ensuring the patient's autonomy is respected.
Choice B is incorrect as designating an MRP focuses on medical decision-making but may not capture the full range of the patient's care preferences. Choice C involves collaboration with an organization, which may not fully represent the patient's individual wishes. Choice D is incorrect as witnesses are not always necessary for providing instructions, and the presence of witnesses does not guarantee that the patient's wishes will be followed accurately.
A patient has herpes simplex 2 viral infection (HSV2). The nurse recognizes that which of the following should be included in teaching the patient?
- A. The virus causes cold sores of the lips.
- B. The virus may be cured with antibiotics.
- C. The virus, when active, may not be contracted during intercourse.
- D. Treatment is aimed at relieving symptoms.
Correct Answer: D
Rationale: The correct answer is D because treatment for HSV2 focuses on relieving symptoms since the virus cannot be cured. Antiviral medications can help manage outbreaks and reduce the frequency and severity of symptoms. Option A is incorrect as HSV2 typically presents as genital herpes, not cold sores on the lips (usually caused by HSV1). Option B is incorrect since antibiotics are ineffective against viruses. Option C is incorrect as HSV2 is most contagious during active outbreaks, making it important to practice safe sex to prevent transmission.
In the past three to four decades, nursing has moved into the forefront in providing care for the dying. Which phenomenon has most contributed to this increased focus of care of the dying?
- A. Increased incidence of infections and acute illnesses
- B. Increased focus of health care providers on disease prevention
- C. Larger numbers of people dying in hospital settings
- D. Demographic changes in the population
Correct Answer: D
Rationale: The correct answer is D: Demographic changes in the population. This is because as the population ages, there is a higher prevalence of chronic illnesses and an increased number of people facing end-of-life care needs. This has led to a greater demand for palliative and hospice care services, shifting the focus of nursing towards providing care for the dying.
A: Increased incidence of infections and acute illnesses is not the primary factor contributing to the increased focus on care for the dying. While these conditions do require nursing care, they do not directly explain the shift in focus.
B: Increased focus of health care providers on disease prevention is important but does not directly explain the increased attention on care for the dying. Disease prevention aims to reduce the incidence of illnesses, not necessarily address end-of-life care needs.
C: Larger numbers of people dying in hospital settings may be a consequence of the increased focus on care for the dying, but it is not the underlying phenomenon driving the shift in nursing care towards end-of
A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of motor function and sensation. The physician suspects the patient has a spinal cord tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose spinal cord compression from a tumor, the nurse will most likely prepare the patient for what test?
- A. Anterior-posterior x-ray
- B. Ultrasound
- C. Lumbar puncture
- D. MRI
Correct Answer: D
Rationale: The correct answer is D: MRI. MRI is the most appropriate test for diagnosing spinal cord compression from a tumor as it provides detailed images of soft tissues, including the spinal cord and surrounding structures. It can accurately identify the location, size, and extent of the tumor. Anterior-posterior x-ray (A) is not as detailed and may not clearly show soft tissue abnormalities. Ultrasound (B) is not typically used for imaging the spinal cord and may not provide sufficient information. Lumbar puncture (C) is used to collect cerebrospinal fluid and is not helpful for diagnosing spinal cord compression from a tumor.