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A patient expresses fear of the unknown regarding an upcoming surgical procedure. What is the nurse's best response?
- A. Dismiss the patient's fear and assure them that the procedure is routine.
- B. Provide the patient with accurate information about the surgical procedure and what to expect.
- C. Ignore the patient's fear and proceed with scheduling the procedure.
- D. Tell the patient that fear of the unknown is irrational and unfounded.
Correct Answer: B
Rationale: The nurse's best response to a patient expressing fear of the unknown regarding an upcoming surgical procedure is to provide the patient with accurate information about the surgical procedure and what to expect. This approach empowers the patient with knowledge and helps alleviate anxiety by demystifying the unknown. By educating the patient about the procedure, potential risks, and postoperative care, the nurse can help the patient feel more prepared and in control of the situation. It is crucial for healthcare providers to address patient fears with compassion, understanding, and information to support the patient through the surgical process.
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When the nurse placed the patient in restraints before using other methods of intervention, she/he violated the patient's rights to ______.
- A. receive confidential and respectful care
- B. provide informed consent
- C. receive treatment in the least restrictive environment
- D. refuse treatment
Correct Answer: C
Rationale: Placing a patient in restraints before utilizing other less restrictive interventions violates the patient's right to receive treatment in the least restrictive environment. Restraints should be used as a last resort when all other options have been exhausted, as they can be restrictive to the patient's movement and freedom. Patients have the right to be treated in a manner that minimizes limitations on their personal freedom and autonomy. Restraints should only be utilized when absolutely necessary for the safety of the patient or others.
A woman in active labor demonstrates persistent occiput posterior fetal position, contributing to prolonged labor and severe back pain. What nursing intervention should be prioritized to facilitate fetal rotation and optimize labor progress?
- A. Assisting the mother into a hands-and-knees position
- B. Administering intravenous opioids for pain relief
- C. Preparing for immediate instrumental delivery
- D. Initiating continuous electronic fetal monitoring
Correct Answer: A
Rationale: Placing the mother in a hands-and-knees position can help facilitate fetal rotation from occiput posterior to the desired occiput anterior position. This position utilizes gravity to assist in the repositioning of the baby, ultimately helping to alleviate back pain and promoting more efficient labor progress. It allows the baby's head to descend properly into the pelvis, potentially reducing the risk of a prolonged labor or the need for instrumental delivery. Additionally, being in this position can help the mother feel more comfortable and empowered during labor. Overall, assisting the mother into a hands-and-knees position is a non-invasive, low-risk intervention that can have a positive impact on both the mother and baby's well-being during labor.
A patient receiving palliative care for end-stage liver cancer experiences severe nausea and vomiting despite antiemetic therapy. What should the palliative nurse consider when addressing the patient's symptoms?
- A. Increase the dosage of the current antiemetic medication.
- B. Switch to a different antiemetic medication with a different mechanism of action.
- C. Discontinue antiemetic therapy and explore non-pharmacological interventions.
- D. Administer intravenous fluids to alleviate dehydration associated with vomiting.
Correct Answer: B
Rationale: When a patient receiving palliative care for end-stage cancer experiences severe nausea and vomiting despite current antiemetic therapy, the palliative nurse should consider switching to a different antiemetic medication with a different mechanism of action. This approach is based on the concept of individual variability in response to medications, as well as the potential development of tolerance to a particular drug. Switching to a different antiemetic with a new mechanism of action can provide the patient with a fresh chance at better symptom control by targeting different receptors or pathways involved in nausea and vomiting. It is important to consult the healthcare team and consider the patient's overall condition and medication history before making any changes in the treatment plan.
Ramon died at 10:00 PM. His father cried much and refused to move Ramon 's body. What is the APPROPRIATE approach of the nurse?
- A. Talk about the reality of death.
- B. Leave the mother and the child for the last time.
- C. Silence to allow the mother to grieve.
- D. Cry with the mother as you remember your own experience of death in family.
Correct Answer: A
Rationale: The appropriate approach of the nurse in this situation would be to talk about the reality of death with the father. It is important to provide appropriate and compassionate communication, acknowledging the father's grief while also gently guiding him towards accepting the reality of the situation. By discussing the reality of death and offering support, the nurse can help the father start the grieving process and eventually come to terms with the loss of his son. It is important to provide emotional support and guidance in a sensitive and respectful manner during such a difficult time.
Upon clinical assessment, the nurse observes that the OUTSTANDING manifestation of the patient is ______.
- A. weight gain
- B. obesity
- C. emaciation
- D. edema
Correct Answer: D
Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.