Nokea
A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
- A. Blowing up balloons
- B. Deliberately frowning
- C. Smiling repeatedly
- D. Whistling
Correct Answer: A
Rationale: The correct answer is A: Blowing up balloons. Blowing up balloons involves the activation of the facial muscles, which helps prevent muscle atrophy in patients with Bell's palsy. This exercise promotes muscle strength and prevents weakness. Deliberately frowning (B), smiling repeatedly (C), and whistling (D) do not specifically target the facial muscles involved in Bell's palsy and may not be as effective in preventing muscle atrophy.
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Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
- A. Abdominal palpation
- B. Venous sample of blood
- C. Checking deep tendon reflexes
- D. Auscultation of the heart and lungs
Correct Answer: A
Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (C), auscultation of the heart and lungs (D), and venous sample of blood (B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.
A student nurse is caring for a patient who has undergone a wide excision of the vulva. The student should know that what action is contraindicated in the immediate postoperative period?
- A. Placing patient in low Fowlers position
- B. Application of compression stockings
- C. Ambulation to a chair
- D. Provision of a low-residue diet
Correct Answer: B
Rationale: The correct answer is B: Application of compression stockings. Immediately after a wide excision of the vulva, compression stockings should be avoided as they can increase the risk of blood clots. Placing the patient in a low Fowler's position helps with comfort and promotes healing. Ambulation to a chair aids in preventing complications like pneumonia and deep vein thrombosis. Providing a low-residue diet is appropriate postoperatively to prevent straining during bowel movements.
A patient, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?
- A. Her two children should be treated with acyclovir before she goes home from the hospital.
- B. The baby will acquire immunity from her and will not be susceptible to chickenpox.
- C. The children can visit their mother and baby in the hospital as planned but must wear gowns and masks.
- D. She must make arrangements to stay somewhere other than her home until the children are no longer contagious.
Correct Answer: D
Rationale: The correct answer is D: She must make arrangements to stay somewhere other than her home until the children are no longer contagious.
1. The patient's newborn is at risk of contracting chickenpox from the infected children.
2. Chickenpox can be severe in newborns due to their immature immune systems.
3. It is crucial to protect the newborn by ensuring they are not exposed to the virus.
4. Staying elsewhere until the children are no longer contagious will prevent transmission to the newborn.
Incorrect choices:
A: Acyclovir is not recommended for prophylactic treatment in this situation.
B: Immunity is not automatically transferred from the mother to the baby for chickenpox.
C: Allowing the infected children to visit with precautions is not sufficient to protect the newborn.
A nurse is designing a form for lesbian, gay,bisexual, and transgender (LGBT) patients. Which design should the nurse use?
- A. Use partnered rather than married.
- B. Use mother rather than father.
- C. Use parents rather than guardian.
- D. Use wife/husband rather than significant other.
Correct Answer: C
Rationale: The correct answer is C: Use parents rather than guardian. This is the most inclusive and respectful choice for LGBT patients as it acknowledges different family structures. LGBT individuals may have non-traditional family dynamics, so using "parents" instead of "guardian" is more appropriate. Option A is incorrect because not all LGBT individuals are in partnerships. Option B is incorrect as it assumes traditional gender roles. Option D is incorrect as not all LGBT individuals may identify with the terms "wife" or "husband."
The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify?
- A. Helping the family to understand why the patient needs to be sedated
- B. Making arrangements to promptly move the patient to an acute-care facility
- C. Explaining to the family that death is near and the patient needs around-the-clock nursing care
- D. Teaching family members how to interact with, and ensure safety for, the patient with impaired cognition
Correct Answer: D
Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being.
Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.