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A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?
- A. Position in semi-Fowler’s.
- B. Flex head with chin tuck.
- C. Place food on left side.
- D. Offer fruit juice.
Correct Answer: B
Rationale: The correct answer is B: Flex head with chin tuck. This position helps prevent aspiration by closing off the airway during swallowing. Flexing the head and tucking the chin promotes safe swallowing and reduces the risk of choking. Placing food on the left side (choice C) is not relevant to addressing the patient's symptoms. Positioning in semi-Fowler's (choice A) may not directly address the swallowing difficulty. Offering fruit juice (choice D) does not address the patient's specific feeding needs and may not be safe if the patient has swallowing difficulties.
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A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patients health status?
- A. For some patients, these recurrent infections constitute an age-related physiologic change.
- B. The patient would benefit from a temporary mobility restriction to facilitate healing.
- C. The patient needs to be assessed for nasopharyngeal cancer.
- D. Blood cultures should be drawn to rule out a systemic infection.
Correct Answer: A
Rationale: Step 1: Serous otitis media is common in children due to eustachian tube dysfunction, not usually related to systemic infections.
Step 2: Recurrent infections may indicate age-related changes like decreased eustachian tube function.
Step 3: Age-related physiologic changes can lead to poor drainage, causing recurrent otitis media.
Step 4: Therefore, choice A is correct as it aligns with the typical presentation of serous otitis media in the context of age.
Summary: Choice B is incorrect as there is no indication for temporary mobility restriction. Choice C is incorrect as serous otitis media does not typically warrant assessment for nasopharyngeal cancer. Choice D is incorrect as blood cultures are not typically indicated for serous otitis media.
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 nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
- A. Maximize the patients fluid intake.
- B. Provide total parenteral nutrition (TPN).
- C. Keep the patients bed linens free of wrinkles.
- D. Provide the patient with snug clothing at all times.
Correct Answer: C
Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity.
A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity.
B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity.
D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.
A nurse is using core measures to reduce healthdisparities. Which group should the nurse focus on to cause themost improvement in core measures?
- A. Caucasians
- B. Poor people
- C. Alaska Natives
- D. American Indians
Correct Answer: B
Rationale: The correct answer is B: Poor people. Focusing on poor people is likely to cause the most improvement in core measures because individuals living in poverty often face multiple barriers to accessing healthcare and have higher rates of chronic conditions. By targeting this group, the nurse can address social determinants of health, improve healthcare access, and address disparities in healthcare outcomes. Other choices (A, C, D) are not as impactful as poverty is a significant factor influencing health disparities.
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.