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A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patients medication regimen. The patient states that she is eager to beat this disease and looks forward to the time that she will no longer require medication. How should the nurse best respond?
- A. You have a great attitude. This will likely shorten the amount of time that you need medications.
- B. In fact, glaucoma usually requires lifelong treatment with medications.
- C. Most people are treated until their intraocular pressure goes below 50 mm Hg.
- D. You can likely expect a minimum of 6 months of treatment.
Correct Answer: B
Rationale: The correct answer is B: In fact, glaucoma usually requires lifelong treatment with medications.
1. Glaucoma is a chronic condition characterized by increased intraocular pressure.
2. Lifelong treatment is usually necessary to manage intraocular pressure and prevent vision loss.
3. Stopping medication prematurely can lead to worsening of the condition.
4. Therefore, the nurse should educate the patient about the need for ongoing medication to manage glaucoma effectively.
Summary:
A: Incorrect. Having a positive attitude is beneficial, but it does not shorten the duration of glaucoma treatment.
C: Incorrect. The target intraocular pressure is usually below 21 mm Hg, not 50 mm Hg.
D: Incorrect. Glaucoma treatment is typically long-term, not limited to 6 months.
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A 66-year-old patient is in a hospice receiving palliative care for lung cancer which has metastasized to the patients liver and bones. For the past several hours, the patient has been experiencing dyspnea. What nursing action is most appropriate to help to relive the dyspnea the patient is experiencing?
- A. Administer a bolus of normal saline, as ordered.
- B. Initiate high-flow oxygen therapy.
- C. Administer high doses of opioids.
- D. Administer bronchodilators and corticosteroids, as ordered.
Correct Answer: B
Rationale: The correct answer is B: Initiate high-flow oxygen therapy. Dyspnea in a patient with lung cancer can be caused by hypoxia due to compromised lung function. High-flow oxygen therapy can help improve oxygenation and alleviate dyspnea. Administering a bolus of normal saline (A) would not directly address the underlying cause of dyspnea. Administering high doses of opioids (C) may lead to respiratory depression and should be used cautiously in patients experiencing dyspnea. Administering bronchodilators and corticosteroids (D) may be appropriate for certain types of dyspnea, but in this case, addressing hypoxia with high-flow oxygen therapy is the most appropriate initial nursing action.
A nurse and a patient work on strategies to reduceweight. Which phase of the helping relationship is the nurse in with this patient?
- A. Preinteraction
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: The correct answer is C: Working. In the working phase, the nurse and patient actively collaborate on achieving goals, such as weight reduction strategies. The nurse assesses, plans, and implements interventions with the patient. During this phase, the focus is on building trust, exploring feelings, and identifying and addressing issues. The other choices are incorrect because in the preinteraction phase (A), there is no direct interaction yet, in the orientation phase (B), the relationship is being established, and in the termination phase (D), the relationship is coming to an end. Thus, the nurse being engaged in weight reduction strategies with the patient indicates that they are in the working phase of the helping relationship.
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 patient is being discharged home from the ambulatory surgery center after an incisional biopsy of a mass in her left breast. What are the criteria for discharging this patient home? Select all that apply.
- A. Patient must understand when she can begin ambulating
- B. Patient must have someone to accompany her home
- C. Patient must understand activity restrictions
- D. Patient must understand care of the biopsy site E) Patient must understand when she can safely remove her urinary catheter
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Ambulating is a crucial postoperative activity to prevent complications like blood clots.
2. Understanding when to ambulate ensures the patient follows proper recovery guidelines.
3. Proper ambulation aids in preventing postoperative complications and promotes healing.
Summary of why other choices are incorrect:
B. Having someone accompany the patient is important for support but not a strict criteria for discharge.
C. While understanding activity restrictions is important, it is not a specific criteria for immediate discharge.
D. Understanding care for the biopsy site is essential but not a strict criteria for immediate discharge.
E. Removal of a urinary catheter is not typically related to discharge criteria for a breast biopsy.
A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem?
- A. The patient requests that her family bring her makeup and wig.
- B. The patient begins to discuss the future with her family.
- C. The patient reports less disruption from pain and discomfort.
- D. The patient cries openly when discussing her disease.
Correct Answer: B
Rationale: The correct answer is B because discussing the future indicates acceptance and hope, a positive step towards improved body image and self-esteem. The patient is focusing on moving forward, which shows emotional growth and resilience. Choice A may provide temporary comfort but does not necessarily address underlying emotional issues. Choice C is related to pain management, not body image or self-esteem. Choice D suggests continued emotional distress rather than progress towards improved self-image.