Nokea
A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
- A. Ineffective Airway Clearance
- B. Impaired Oral Mucous Membranes
- C. Imbalanced Nutrition: Less than Body Requirements
- D. Activity Intolerance
Correct Answer: A
Rationale: The correct answer is A: Ineffective Airway Clearance. In a patient with AIDS and PCP, maintaining clear airways is crucial to prevent respiratory distress and hypoxia. Pneumocystis pneumonia can cause thick secretions and mucus plugging, leading to difficulty breathing. Ensuring effective airway clearance is a priority to optimize oxygenation and prevent respiratory complications. Impaired oral mucous membranes (B) and imbalanced nutrition (C) are important considerations but not as immediate as airway clearance. Activity intolerance (D) may be a concern for the patient but ensuring adequate oxygenation takes precedence.
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The home health nurse is performing a home visit for an oncology patient discharged 3 days ago after completing treatment for non-Hodgkin lymphoma. The nurses assessment should include examination for the signs and symptoms of what complication?
- A. Tumor lysis syndrome (TLS)
- B. Syndrome of inappropriate antiduretic hormone (SIADH)
- C. Disseminated intravascular coagulation (DIC)
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Tumor lysis syndrome (TLS). In this scenario, the oncology patient has completed treatment for non-Hodgkin lymphoma. TLS is a potential complication post-treatment due to the rapid breakdown of cancer cells, leading to release of intracellular contents like potassium, phosphorus, and uric acid into the bloodstream. This can result in electrolyte imbalances, renal failure, and cardiac arrhythmias. The nurse should assess for signs such as hyperkalemia, hyperphosphatemia, hypocalcemia, and elevated uric acid levels. Monitoring renal function and fluid status is crucial.
Summary of other choices:
B: Syndrome of inappropriate ADH (SIADH) is characterized by excessive release of antidiuretic hormone leading to water retention and dilutional hyponatremia. Not typically associated with post-treatment complications in oncology patients.
C: Disseminated intravascular coagulation (DIC)
A nurse practitioner is examining a patient who presented at the free clinic with vulvar pruritus. For which assessment finding would the practitioner look that may indicate the patient has an infection caused by Candida albicans?
- A. Cottage cheese-like discharge
- B. Yellow-green discharge
- C. Gray-white discharge
- D. Watery discharge with a fishy odor
Correct Answer: A
Rationale: The correct answer is A: Cottage cheese-like discharge. Candida albicans is a common cause of vulvovaginal candidiasis, characterized by itching and cottage cheese-like discharge. This type of discharge is specific to a yeast infection. Yellow-green discharge (choice B) is indicative of trichomoniasis, gray-white discharge (choice C) is seen in bacterial vaginosis, and watery discharge with a fishy odor (choice D) is characteristic of bacterial vaginosis or trichomoniasis. Therefore, the presence of cottage cheese-like discharge is a key indicator of a Candida albicans infection.
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
- A. Assess the patient for any previous inability to self-manage medications.
- B. Ask the patient to demonstrate the instillation of her medications.
- C. Determine whether the patient can accurately describe the appropriate method of administering her medications.
- D. Assess the patients functional status.
Correct Answer: B
Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
- A. Care of the cervical collar
- B. Technique for performing neck ROM exercises
- C. Home assessment of ABGs
- D. Techniques for restoring nerve function
Correct Answer: A
Rationale: Correct Answer: A - Care of the cervical collar
Rationale:
1. Care of the cervical collar is essential post-cervical diskectomy to ensure proper immobilization and support.
2. Proper care prevents complications and promotes healing.
3. It is a crucial aspect of discharge education to prevent injury and promote recovery.
Summary of other choices:
B: Technique for performing neck ROM exercises - Important for rehabilitation but not directly related to discharge education post-cervical diskectomy.
C: Home assessment of ABGs - Irrelevant to post-cervical diskectomy discharge education.
D: Techniques for restoring nerve function - Important for recovery but not a primary focus of discharge education.
A 5-year-old boy has been diagnosed with a severe food allergy. What is an important parameter to address when educating the parents of this child about his allergy and care?
- A. Wear a medical identification bracelet.
- B. Know how to use the antihistamine pen.
- C. Know how to give injections of lidocaine.
- D. Avoid live attenuated vaccinations.
Correct Answer: A
Rationale: The correct answer is A: Wear a medical identification bracelet. This is important because in case of an emergency, such as an allergic reaction, medical professionals need to be aware of the child's severe food allergy quickly. The bracelet provides crucial information that can help in providing timely and appropriate medical care.
B: Knowing how to use the antihistamine pen is also important in managing allergic reactions, but wearing a medical identification bracelet takes precedence as it provides immediate identification of the allergy.
C: Knowing how to give injections of lidocaine is not relevant to managing a food allergy in a child.
D: Avoiding live attenuated vaccinations may be necessary for individuals with certain allergies, but it is not directly related to educating parents about managing the child's food allergy.