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A nurse is pouching an ostomy on a patient withan ileostomy. Which action by the nurse ismostappropriate?
- A. Changing the skin barrier portion of the ostomy pouch daily
- B. Emptying the pouch if it is more than one-third to one-half full
- C. Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive
- D. Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma
Correct Answer: B
Rationale: The correct answer is B, emptying the pouch if it is more than one-third to one-half full. This action is appropriate to prevent leakage and skin irritation. When the pouch becomes too full, it can put pressure on the seal, leading to potential leaks. Emptying the pouch at one-third to one-half fullness helps maintain a secure seal and prevents skin breakdown.
Choice A is incorrect because changing the skin barrier portion of the ostomy pouch daily is unnecessary and can lead to skin irritation and breakdown.
Choice C is incorrect because cleansing the skin around the stoma with soap and water excessively can strip the skin of its natural oils and cause irritation.
Choice D is incorrect because leaving a 1/2-inch space around the stoma when measuring for the barrier device may result in an improper fit, leading to leakage and skin issues.
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A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea?
- A. Zithromax
- B. Sandostatin
- C. Levaquin
- D. Biaxin
Correct Answer: B
Rationale: The correct answer is B: Sandostatin. This drug is a somatostatin analog that can help manage HIV-related chronic severe diarrhea by reducing gastrointestinal secretions. Sandostatin works by inhibiting the release of various hormones and neurotransmitters in the gut, which can help control diarrhea in HIV patients.
Rationale:
A: Zithromax is an antibiotic that is not typically used to manage chronic severe diarrhea in HIV patients.
C: Levaquin is also an antibiotic and not indicated for managing diarrhea in HIV patients.
D: Biaxin is another antibiotic and not the appropriate choice for managing chronic severe diarrhea in HIV patients.
In summary, Sandostatin is the correct choice as it specifically targets the underlying cause of diarrhea in HIV patients by reducing gastrointestinal secretions, whereas the other options are antibiotics that are not indicated for this purpose.
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.
A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patients care, the nurse should be aware that the effects of the tumor will primarily depend on what variable?
- A. Whether the tumor utilizes aerobic or anaerobic respiration
- B. The specific hormones secreted by the tumor
- C. The patients pre-existing health status
- D. Whether the tumor is primary or the result of metastasis
Correct Answer: B
Rationale: The correct answer is B: The specific hormones secreted by the tumor. Pituitary adenomas are known to secrete hormones that can lead to various endocrine disorders. Understanding the specific hormones secreted by the tumor is crucial in determining the clinical manifestations and planning appropriate treatment. Choices A, C, and D are incorrect because the primary determinant of the effects of the tumor in this case is the hormonal activity rather than whether the tumor uses aerobic or anaerobic respiration, the patient's pre-existing health status, or whether the tumor is primary or metastatic.
Which finding would indicate concealed hemorrhage in abruptio placentae?
- A. Bradycardia
- B. Hard boardlike abdomen
- C. Decrease in fundal height
- D. Decrease in abdominal pain
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention.
Rationale:
A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae.
C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage.
D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment?
- A. Is she able to tell her family of negative test results?
- B. Does she have a sense of peace of mind and a purpose to her life?
- C. Can she let go of her husband so he can make a new life?
- D. Does she need time and space to bargain with God for a cure?
Correct Answer: B
Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty.
Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.