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A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?
- A. Applying a protective eye shield at night
- B. Chewing on the affected side to prevent unilateral neglect
- C. Avoiding the use of analgesics whenever possible
- D. Avoiding brushing the teeth
Correct Answer: A
Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications.
Summary of Incorrect Choices:
B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial.
C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms.
D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.
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A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?
- A. Amino acids
- B. Triglycerides
- C. Dispensable amino acids
- D. Indispensable amino acids
Correct Answer: D
Rationale: Rationale:
1. Indispensable amino acids, also known as essential amino acids, must be obtained through the diet as the body cannot synthesize them.
2. Amino acids are the building blocks of proteins, so mentioning "indispensable amino acids" indicates understanding of essential dietary proteins.
3. Triglycerides are fats, not proteins, and not related to essential amino acids.
4. Dispensable amino acids can be synthesized by the body, so mentioning them would not indicate understanding of essential proteins.
A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
- A. More aggressive chemotherapy
- B. Left mastectomy
- C. Radiation therapy
- D. Bilateral mastectomy
Correct Answer: D
Rationale: The correct answer is D: Bilateral mastectomy. This intervention involves removing both breasts to reduce the risk of developing breast cancer in the future. For a woman with a history of breast cancer in one breast, opting for bilateral mastectomy can significantly decrease the likelihood of cancer recurrence. This proactive approach is often recommended for individuals with a high risk of developing breast cancer.
Explanation for why the other choices are incorrect:
A: More aggressive chemotherapy - Chemotherapy is typically used to treat existing cancer cells, not as a prophylactic measure to prevent cancer.
B: Left mastectomy - This option only removes the affected breast, not addressing the risk of cancer developing in the other breast.
C: Radiation therapy - While radiation therapy can be used as part of the treatment for breast cancer, it is not a prophylactic measure to prevent future cancer development in the contralateral breast.
An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply
- A. Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously.
- B. Cholesteatomas are usually the result of metastasis from a distant tumor site.
- C. Cholesteatomas are often the result of chronic otitis media.
- D. Cholesteatomas, if left untreated, result in intractable neuropathic pain. E) Cholesteatomas usually must be removed surgically.
Correct Answer: C
Rationale: The correct answer is C. Cholesteatomas are often the result of chronic otitis media. Chronic otitis media can lead to the formation of cholesteatomas, which are noncancerous but can cause complications if left untreated. Cholesteatomas do not resolve spontaneously (A), are not the result of metastasis (B), do not typically cause intractable neuropathic pain (D), and usually require surgical removal to prevent complications (E). Therefore, educating the patient about the association between chronic otitis media and cholesteatoma is essential for understanding the diagnosis and potential treatment options.
A nurse is sitting at the patient’s bedside takinga nursing history. Which zone of personal space is the nurse using?
- A. Socio-consultative
- B. Personal
- C. Intimate
- D. Public
Correct Answer: B
Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (C) is 0-18 inches, too close for an initial nursing history. The public zone (D) is 12 feet or more, too distant for a personal conversation.
A nurse is caring for a group of patients. Which patient will the nurse seefirst?
- A. Patient receiving total parenteral nutrition of 2-in-1 for 50 hours
- B. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours
- C. Patient receiving continuous enteral feeding with same feeding bag for 12 hours
- D. Patient receiving continuous enteral feeding with same tubing for 24 hours
Correct Answer: B
Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.