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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 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.
The nurse is providing health education to the parents of a toddler who has been diagnosed with food allergies. What should the nurse teach this family about the childs health problem?
- A. Food allergies are a life-long condition, but most families adjust quite well to the necessary lifestyle changes.
- B. Consistent use of over-the-counter antihistamines can often help a child overcome food allergies.
- C. Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants.
- D. Many children outgrow their food allergies in a few years if they avoid the offending foods.
Correct Answer: A
Rationale: Food allergies are a serious health concern that can have life-threatening consequences if not managed properly. It is important for the nurse to educate the family that food allergies are typically life-long conditions and cannot be fully cured. While some children may outgrow certain food allergies over time, it is not guaranteed for all cases. Therefore, the focus should be on effectively managing the allergy through avoidance of trigger foods, carrying emergency medications like epinephrine auto-injectors, and being prepared to respond to allergic reactions. Adjusting to the necessary lifestyle changes, such as reading food labels, informing others about the child's allergies, and being vigilant about potential allergen exposure, is essential for ensuring the child's safety and well-being. Consistent monitoring and communication with healthcare providers are also crucial components of managing food allergies on a long-term basis.
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?
- A. To promote autonomy
- B. To use common courtesy
- C. To establish trustworthiness
- D. To standardize communication
Correct Answer: D
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.
The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that he effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply.
- A. Intracranial hemorrhage
- B. Infection of cerebrospinal fluid
- C. Increased ICP
- D. Focal neurologic signs E) Altered pituitary function
Correct Answer: A
Rationale: Neoplasms can cause pathophysiologic events such as intracranial hemorrhage and increased intracranial pressure (ICP) due to expansion of the mass within the confined space of the skull. Intracranial hemorrhage can occur as the neoplasm damages blood vessels in the brain or causes them to become more fragile. Increased ICP can result from the growing mass causing compression of surrounding structures and obstructing the flow of cerebrospinal fluid, leading to symptoms such as headaches, nausea, vomiting, and changes in mental status.
The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work? What would be the nurses best response?
- A. Yes, its known to have a slight protective effect.
- B. Yes, but studies also show an increased risk of osteoporosis.
- C. You wont need to worry about getting cancer as long as you take Tamoxifen.
- D. Tamoxifen is known to be a highly effective protective measure.
Correct Answer: A
Rationale: The nurse's best response should be to provide accurate information and manage the patient's expectations realistically. Tamoxifen is known to have a slight protective effect in reducing the risk of developing breast cancer in high-risk individuals like the patient in the scenario. However, it is not a guarantee against developing breast cancer. It is essential for the nurse to convey this information to the patient to ensure that she understands the benefits and limitations of Tamoxifen therapy. Additionally, discussing potential side effects and risks associated with Tamoxifen, such as an increased risk of osteoporosis, is important for the patient to make an informed decision about her health care.