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A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action?
- A. Instill the medication in the conjunctival sac.
- B. Maintain a supine position for 10 minutes after administration.
- C. Keep the eyes closed for 1 to 2 minutes after administration.
- D. Apply the medication evenly to the sclera
Correct Answer: A
Rationale: The correct answer is A because instilling the medication in the conjunctival sac allows for direct absorption into the eye tissues. This method ensures that the medication reaches the target area for treating glaucoma effectively. Maintaining a supine position (choice B) or keeping the eyes closed (choice C) after administration does not enhance absorption and may lead to wasted medication. Applying the medication to the sclera (choice D) is incorrect as it does not target the specific area needed for treating glaucoma.
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A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
- A. Herpes simplex
- B. HIV
- C. Spina bifida
- D. Hypogammaglobulinemia
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems.
Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies.
Choice B: HIV weakens the immune system but is not specifically associated with latex allergies.
Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.
A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection- related death in oncology patients?
- A. Encourage several small meals daily.
- B. Provide skin care to maintain skin integrity.
- C. Assist the patient with hygiene, as needed.
- D. Assess the integrity of the patients oral mucosa regularly.
Correct Answer: D
Rationale: The correct answer is D: Assess the integrity of the patients oral mucosa regularly. Myelosuppression leads to decreased white blood cells, increasing infection risk. The oral mucosa can be a common site for infections. Regular assessment helps in early detection and intervention.
A: Encouraging small meals does not directly address infection risk in myelosuppressed patients.
B: Providing skin care is important for overall patient care but does not directly address the leading cause of infection-related death.
C: Assisting with hygiene is important but does not specifically target the leading cause of infection-related death in oncology patients.
A nurse is using therapeutic communication witha patient. Which technique will the nurse use to ensure effective communication?
- A. Interpersonal communication to change negative self-talk to positive self-talk
- B. Small group communication to present information to an audience
- C. Electronic communication to assess a patient in another city
- D. Intrapersonal communication to build strong teams
Correct Answer: A
Rationale: The correct answer is A because therapeutic communication focuses on building a trusting relationship and understanding the patient's feelings and needs. By changing negative self-talk to positive self-talk, the nurse can help the patient develop a more positive outlook and improve self-esteem. This technique promotes effective communication by creating a supportive and non-judgmental environment.
Option B is incorrect because small group communication is not the primary focus of therapeutic communication. Option C is incorrect as electronic communication lacks the personal interaction needed for therapeutic communication. Option D is incorrect because intrapersonal communication involves self-reflection and is not directly related to building strong teams in the context of patient care.
A nurse is caring for patients with dysphagia. Which patient has neurogenic dysphagia?
- A. A patient with benign peptic stricture
- B. A patient with muscular dystrophy
- C. A patient with myasthenia gravis
- D. A patient with stroke
Correct Answer: D
Rationale: The correct answer is D because neurogenic dysphagia is caused by neurological conditions affecting swallowing function, such as a stroke. In a stroke, damage to the brain can impair the coordination of swallowing muscles, leading to dysphagia.
Choice A is incorrect because benign peptic stricture is a narrowing of the esophagus due to chronic acid reflux, not a neurological issue.
Choice B is incorrect because muscular dystrophy is a genetic disorder that affects muscle strength and does not directly impact the neurological control of swallowing.
Choice C is incorrect because myasthenia gravis is an autoimmune disorder that affects neuromuscular transmission but is not typically associated with neurogenic dysphagia.
In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?
- A. Weight increases.
- B. Weight decreases.
- C. Weight does not change.
- D. Weight fluctuates daily.
Correct Answer: C
Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance.
A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain.
B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss.
D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.