Nokea
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
- A. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence
- B. A patient with reflex incontinence with elevated blood pressure and pulse rate
- C. A patient with an indwelling catheter that has stool on the catheter tubing
- D. A patient who has just voided and needs a postvoid residual test
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention.
Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B.
Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B.
Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
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A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is N R I G B.C M U S N T O based on which of the following?
- A. Hemorrhage is the primary concern.
- B. She will be unable to conceive in the future.
- C. Bed rest and analgesics are the recommended treatment.
- D. A D&C will be performed to remove the products of conception.
Correct Answer: A
Rationale: The correct answer is A because hemorrhage is the primary concern in ectopic pregnancy due to the risk of rupture and severe bleeding. Immediate intervention is crucial to prevent life-threatening complications.
Choice B is incorrect as future fertility may be affected but is not the immediate concern. Choice C is incorrect as bed rest and analgesics are not effective treatments for ectopic pregnancy. Choice D is incorrect as a D&C is not performed in ectopic pregnancy; surgical intervention is required to remove the ectopic pregnancy.
While taking a health history on a 20-year-old female patient, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse is justified in presuming that this patient has what medical condition?
- A. Bacterial vaginosis
- B. Human papillomavirus (HPV)
- C. Candidiasis
- D. Toxic shock syndrome (TSS)
Correct Answer: C
Rationale: Rationale for Correct Answer (C): The nurse can presume the patient has candidiasis since miconazole is commonly used to treat fungal infections like vaginal yeast infections caused by Candida. This medication works by stopping the growth of the fungus. Therefore, the patient's use of miconazole indicates a probable diagnosis of candidiasis.
Summary of Incorrect Choices:
A (Bacterial vaginosis): Miconazole is not used to treat bacterial infections like bacterial vaginosis, which is caused by an imbalance of bacteria in the vagina.
B (HPV): Miconazole is not used to treat viral infections like HPV, which is a sexually transmitted infection caused by certain types of human papillomavirus.
D (TSS): Miconazole is not used to treat toxic shock syndrome, which is a severe complication of certain bacterial infections and is not typically associated with miconazole use.
A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patients preoperative teaching?
- A. The procedure is an effective, time-tested treatment for sensory hearing loss.
- B. The patient is likely to experience resolution of conductive hearing loss after the procedure.
- C. Several months of post-procedure rehabilitation will be needed to maximize benefits.
- D. The procedure is experimental, but early indications suggest great therapeutic benefits.
Correct Answer: B
Rationale: The correct answer is B: The patient is likely to experience resolution of conductive hearing loss after the procedure. This information is crucial to include in the preoperative teaching because it directly addresses the patient's expected outcome, providing reassurance and setting appropriate expectations. Stapedectomy with prosthesis insertion is a well-established treatment for otosclerosis-related conductive hearing loss. Choices A, C, and D are incorrect because they either provide misleading information (A, D) or are not directly relevant to the procedure or the patient's immediate postoperative experience (C). It is important to focus on accurate and relevant information to prepare the patient effectively for the upcoming surgery and its expected outcomes.
A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle?
- A. The patient is likely to have an increased appetite.
- B. The patient is likely to required enzyme supplements.
- C. The patient will likely require a clear liquid diet.
- D. The patient will benefit from a low-protein diet.
Correct Answer: D
Rationale: The correct answer is D - The patient will benefit from a low-protein diet. Patients with Huntington disease often experience difficulty swallowing and may have involuntary movements, leading to weight loss. A low-protein diet can help manage these symptoms and reduce the risk of aspiration pneumonia. This diet can also help control the chorea movements associated with the disease.
Choice A is incorrect as patients with Huntington disease often have reduced appetite due to swallowing difficulties. Choice B is incorrect as enzyme supplements are not typically indicated in the management of Huntington disease. Choice C is incorrect as a clear liquid diet is not suitable for meeting the nutritional needs of a patient with Huntington disease, who may already be at risk for malnutrition.
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
- A. Risk for Infection Related to Skin Sloughing
- B. Risk for Acute Pain Related to Loss of Skin Integrity
- C. Risk for Impaired Skin Integrity Related to Cutaneous Lesions
- D. Risk for Impaired Gas Exchange Related to Airway Obstruction
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function.
A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange.
B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise.
C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.