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A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?
- A. Metastasis
- B. Risk for stroke
- C. Emotional and personality changes
- D. Pathologic bone fractures
Correct Answer: C
Rationale: The correct answer is C: Emotional and personality changes. In Huntington disease, neurodegeneration affects the brain, leading to changes in behavior, emotions, and personality. These changes are characteristic of the disease progression. Metastasis (A) refers to the spread of cancer, which is not associated with Huntington disease. Risk for stroke (B) is not a typical manifestation of Huntington disease. Pathologic bone fractures (D) are not directly related to the primary symptoms of Huntington disease. Thus, addressing emotional and personality changes is crucial in providing anticipatory guidance for individuals with Huntington disease.
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The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
- A. Maintain the irrigation fluid at a warm temperature.
- B. Instill short, sharp bursts of fluid into the ear canal.
- C. Follow the procedure with insertion of a cerumen curette to extract missed ear wax.
- D. Have the patient stand during the procedure.
Correct Answer: A
Rationale: Correct Answer: A. Maintain the irrigation fluid at a warm temperature.
Rationale:
1. Warm fluid helps prevent vertigo and nausea by minimizing stimulation of the vestibular system.
2. Cold fluid can cause dizziness and nausea due to the temperature effect on the inner ear.
3. Warm fluid promotes patient comfort and relaxation during the procedure.
4. Cold fluid can lead to vasoconstriction, potentially exacerbating ear discomfort.
Summary of other choices:
B. Instilling short, sharp bursts of fluid can be uncomfortable and increase the risk of vertigo and nausea.
C. Following with a curette may not be necessary if the irrigation effectively removes the impacted cerumen.
D. Having the patient stand can increase the risk of falling or losing balance due to potential dizziness from the procedure.
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
- A. Oral temperature of 100F
- B. Tachypnea and restlessness
- C. Frequent loose stools
- D. Weight loss of 1 pound since yesterday
Correct Answer: B
Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure.
Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition.
Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario.
Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.
A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of motor function and sensation. The physician suspects the patient has a spinal cord tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose spinal cord compression from a tumor, the nurse will most likely prepare the patient for what test?
- A. Anterior-posterior x-ray
- B. Ultrasound
- C. Lumbar puncture
- D. MRI
Correct Answer: D
Rationale: The correct answer is D: MRI. MRI is the most appropriate test for diagnosing spinal cord compression from a tumor as it provides detailed images of soft tissues, including the spinal cord and surrounding structures. It can accurately identify the location, size, and extent of the tumor. Anterior-posterior x-ray (A) is not as detailed and may not clearly show soft tissue abnormalities. Ultrasound (B) is not typically used for imaging the spinal cord and may not provide sufficient information. Lumbar puncture (C) is used to collect cerebrospinal fluid and is not helpful for diagnosing spinal cord compression from a tumor.
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?
- A. These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies.
- B. These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer.
- C. Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy.
- D. Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's symptoms, reassures monitoring, and addresses the cause. It validates his experience while offering a proactive approach. Choice B is incorrect as it dismisses the patient's symptoms and can cause distress. Choice C is incorrect because it generalizes the patient's experience and lacks individualized care. Choice D is incorrect as it may give false hope and oversimplifies the situation. A provides the best balance of empathy and information for the patient's well-being.
Which data found on a patient’s health history would place her at risk for an ectopic pregnancy?
- A. Ovarian cyst 2 years ago
- B. Recurrent pelvic infections
- C. Use of oral contraceptives for 5 years
- D. Heavy menstrual flow of 4 days’ duration
Correct Answer: B
Rationale: The correct answer is B: Recurrent pelvic infections. Pelvic infections can lead to scarring and blockage of the fallopian tubes, increasing the risk of ectopic pregnancy. Ovarian cysts and oral contraceptives are not directly linked to ectopic pregnancies. Heavy menstrual flow does not inherently increase the risk of ectopic pregnancy.