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A patient has a documented history of allergies presents to the clinic. She states that she is frustrated by her chronic nasal congestion, anosmia (inability to smell) and inability to concentrate. The nurse should identify which of the following nursing diagnoses?
- A. Deficient Knowledge of Self-Care Practices Related to Allergies
- B. Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modification
- C. Acute Confusion Related to Cognitive Effects of Allergic Rhinitis
- D. Disturbed Body Image Related to Sequelae of Allergic Rhinitis
Correct Answer: B
Rationale: The patient's frustration with chronic nasal congestion, anosmia, and inability to concentrate indicates difficulty coping with the long-term nature of her condition and the impact it has on her daily life. Additionally, her desire for relief suggests a need for environmental modifications to help manage her symptoms. This nursing diagnosis encompasses the patient's emotional response to her condition, as well as the potential need for changes in her surroundings to better support her health and well-being.
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A nurse is standing beside the patient’s bed. Nurse:How are you doing? Patient:I don’t feel good. Which element will the nurse identify as feedback?
- A. Nurse
- B. Patient
- C. How are you doing?
- D. I don’t feel good.
Correct Answer: D
Rationale: In communication, feedback is the response or message provided by the receiver to the sender. In this scenario, the nurse asks the patient, "How are you doing?" The patient's response, "I don't feel good," is the feedback. It is the patient's reaction and message returning to the nurse. The nurse, in this context, is the sender initiating the conversation, while the patient is the receiver providing the feedback in response to the nurse's inquiry. Therefore, the statement "I don't feel good" constitutes the feedback in this communication exchange.
A nurse is providing care to a group of patients.Which situation will require the nurse to obtain a telephone order?
- A. As the nurse and health care provider leave a patient’s room, the primary care provider gives the nurse an order.
- B. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
- C. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
- D. A nurse reads an order correctly as written by the health care provider in the patient’s medical record
Correct Answer: B
Rationale: In this situation, the nurse needs to obtain a telephone order because the patient's condition has changed significantly. The drop in blood pressure from 120/80 to 90/50 along with the saturated incision dressing indicates a potential complication or need for immediate intervention. The nurse must act quickly to address the situation and may require additional orders from the primary care provider over the phone to manage the patient's condition effectively. The urgency and critical nature of the situation necessitate obtaining a telephone order promptly to ensure the best outcome for the patient.
A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim?
- A. To prioritize emotional needs
- B. To prevent and relieve suffering
- C. To bridge between curative care and hospice care
- D. To provide care while there is still hope
Correct Answer: B
Rationale: The primary aim when transitioning a patient with rapid cancer metastases from active treatment to palliative care is to prevent and relieve suffering. Palliative care focuses on enhancing quality of life, managing symptoms, and addressing physical, emotional, and spiritual needs. By prioritizing the prevention and relief of suffering, healthcare providers can work towards improving the patient's comfort and overall well-being during this difficult time. This approach aligns with the goals of palliative care, which aim to provide holistic support and care for patients facing serious illnesses like cancer.
Which assessment by the nurNseU wRoSuIldN dGiffTerBen.tiCatOe Ma placenta previa from an abruptio placentae?
- A. Saturated perineal pad in 1 hour
- B. Pain level 0 on a scale of 0 to 10
- C. Cervical dilation at 2 cm
- D. Fetal heart rate at 160 bpm
Correct Answer: A
Rationale: In the assessment of a patient with potential placenta previa or abruptio placentae, the nurse should pay close attention to the amount and characteristics of vaginal bleeding. Placenta previa typically presents with painless vaginal bleeding, which can be sudden and significant. Therefore, a saturated perineal pad within a short period of time (1 hour) is more indicative of placenta previa, as opposed to abruptio placentae which usually presents with painful vaginal bleeding and may not necessarily saturate a perineal pad quickly. Monitoring the amount of bleeding and keeping track of pad saturation over time can provide valuable information to differentiate between these two conditions.
Patients who are enrolled in hospice care through Medicare are often felt to suffer unnecessarily because they do not receive adequate attention for their symptoms of the underlying illness. What factor most contributes to this phenomenon?
- A. Unwillingness to overmedicate the dying patient
- B. Rules concerning completion of all cure-focused medical treatment
- C. Unwillingness of patients and families to acknowledge the patient is terminal
- D. Lack of knowledge of patients and families regarding availability of care
Correct Answer: C
Rationale: The factor that most contributes to patients in hospice care not receiving adequate attention for their symptoms of the underlying illness is the unwillingness of patients and families to acknowledge that the patient is terminal. When patients and families are in denial or struggle to accept the terminal nature of the illness, they may avoid focusing on symptom management and comfort care that is essential in hospice care. This can prevent healthcare providers from effectively addressing and managing the patient's symptoms, leading to unnecessary suffering for the patient. Accepting the terminal nature of the illness allows for a shift in focus towards providing quality end-of-life care that prioritizes symptom management and comfort for the patient.