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A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should encourage the patient to:
- A. Avoid deep breathing exercises to prevent pain.
- B. Take shallow breaths to minimize pain.
- C. Perform deep breathing exercises to prevent pneumonia.
- D. Limit mobility to avoid stress on the surgical site.
Correct Answer: C
Rationale: Step 1: Post-operative patients are at risk for developing pneumonia due to decreased lung expansion and secretion retention.
Step 2: Deep breathing exercises help improve lung expansion and prevent pneumonia.
Step 3: Therefore, encouraging the patient to perform deep breathing exercises is essential.
Summary:
- A: Avoiding deep breathing exercises is incorrect as it can lead to respiratory complications.
- B: Taking shallow breaths can worsen lung function and increase the risk of pneumonia.
- D: Limiting mobility can lead to complications like blood clots and pneumonia.
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A man has come in to the clinic because he is afraid he might have skin cancer. During the skin assessment, the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on' on his skin. Which of the following is the best prediction?
- A. He probably has senile lentigines, which do not become cancerous.
- B. He probably has actinic keratoses, precursors to basal cell carcinoma.
- C. He probably has acrochordons, precursors to squamous cell carcinoma.
- D. He probably has seborrheic keratosis, which do not become cancerous.
Correct Answer: D
Rationale: The correct answer is D: He probably has seborrheic keratosis, which do not become cancerous. Seborrheic keratosis typically appear as greasy, dark, and "stuck on" pigmented growths on the skin, commonly seen in older adults. They are benign and do not progress to skin cancer. This conclusion is based on the characteristics of seborrheic keratosis and the fact that they are not associated with malignancy.
Choice A (senile lentigines) is incorrect because although they are also common in older adults, they are flat and dark spots rather than raised growths. Choice B (actinic keratoses) is incorrect as they are precancerous lesions related to sun exposure, leading to a risk of developing squamous cell carcinoma, not basal cell carcinoma. Choice C (acrochordons) are skin tags and not precursors to squamous cell carcinoma.
A nurse is frequently bothered when a patient does not take the medications as prescribed until the patient speaks with her family. The nurse is so irritated by this behaviour that he often finds it hard to provide appropriate care to this individual. What should the nurse do first in trying to overcome his difficulty?
- A. Identify the meaning of family inclusion to the patient
- B. Understand that this is a cultural practice that is helpful to the patient
- C. Allow the patient to take her medications only when she feels comfortable
- D. Discuss with the patient the importance of independent health decisions
Correct Answer: B
Rationale: Step 1: Recognize Cultural Sensitivity - Understanding that family inclusion is a cultural practice is crucial as it helps the nurse appreciate the patient's perspective. Step 2: Empathy - Acknowledging the significance of family involvement for the patient shows empathy and respect for their beliefs and values. Step 3: Effective Communication - By recognizing and respecting the cultural practice, the nurse can build a trusting relationship with the patient and her family, leading to better adherence to medication and improved care outcomes. In summary, Option B is correct as it emphasizes cultural competence and patient-centered care. Options A, C, and D are incorrect as they do not address the core issue of cultural understanding and may hinder effective communication and relationship-building with the patient and her family.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
- A. Pulmonary embolism.
- B. Pneumothorax.
- C. Hypercapnia.
- D. Asthma attack.
Correct Answer: C
Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure.
Incorrect choices:
A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD.
B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication.
D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.
A nurse is caring for a patient with diabetes. The nurse should monitor for which of the following complications?
- A. Hypoglycemia.
- B. Hyperkalemia.
- C. Hypotension.
- D. Hyperglycemia.
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. In diabetes, hyperglycemia occurs when blood sugar levels are too high. This can lead to various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. Monitoring for hyperglycemia is crucial to prevent these serious complications.
A: Hypoglycemia is low blood sugar and can also occur in diabetes, but it is not the primary complication to monitor for in this case.
B: Hyperkalemia is high potassium levels and is not a common complication of diabetes unless there are other underlying issues.
C: Hypotension is low blood pressure, which can be a complication of diabetes but is not as directly related to glucose management as hyperglycemia.
In summary, monitoring for hyperglycemia is essential in diabetes care to prevent serious complications associated with high blood sugar levels.
A nurse is teaching a patient with osteoarthritis about managing their condition. Which of the following statements by the patient indicates the need for further education?
- A. I will use heat or cold therapy to relieve joint pain.
- B. I will take my pain medication regularly.
- C. I will exercise regularly to strengthen my joints.
- D. I will avoid physical activity to prevent joint strain.
Correct Answer: D
Rationale: The correct answer is D because avoiding physical activity to prevent joint strain is not recommended for managing osteoarthritis. Exercise is crucial for strengthening joints and improving flexibility. Choice A is correct as heat or cold therapy can help relieve joint pain. Choice B is correct as taking pain medication regularly can help manage symptoms. Choice C is correct as regular exercise is important for maintaining joint health. In summary, avoiding physical activity is not a recommended approach for managing osteoarthritis, unlike the other choices which are beneficial for the condition.