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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.
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A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
- A. Forearm
- B. Thigh
- C. Deltoid muscle
- D. Abdomen
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
- A. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence
- B. A patient with reflex incontinence with elevated blood pressure and pulse rate
- C. A patient with an indwelling catheter that has stool on the catheter tubing
- D. A patient who has just voided and needs a postvoid residual test
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention.
Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B.
Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B.
Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
A nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel?
- A. Obtaining a midstream urine specimen
- B. Interpreting a bladder scan result
- C. Inserting a straight catheter
- D. Irrigating a catheter
Correct Answer: A
Rationale: The correct answer is A: Obtaining a midstream urine specimen. This task is within the scope of practice for nursing assistive personnel as it involves collecting a specimen, which is a routine and non-invasive procedure. Nursing assistive personnel are trained to perform basic tasks like specimen collection. Choices B, C, and D involve more complex skills and procedures that require specialized training and knowledge, which are typically performed by licensed nurses. Interpreting bladder scan results (B), inserting a straight catheter (C), and irrigating a catheter (D) all require a higher level of expertise and assessment that nursing assistive personnel are not qualified to do.
A nurse is providing care to a culturally diversepopulation. Which action indicates the nurse is successful in the role of providing culturally congruent care?
- A. Provides care that fits the patient’s valued life patterns and set of meanings
- B. Provides care that is based on meanings generated by predetermined criteria
- C. Provides care that makes the nurse the leader in determining what is needed
- D. Provides care that is the same as the values of the professional health care system
Correct Answer: A
Rationale: The correct answer is A because providing care that fits the patient's valued life patterns and set of meanings demonstrates cultural congruence. This approach acknowledges and respects the patient's cultural background, beliefs, and preferences. It promotes patient-centered care and enhances communication and trust between the nurse and the patient.
Choice B is incorrect because care based on predetermined criteria may not align with the patient's individual cultural needs. Choice C is incorrect as it does not prioritize the patient's values and preferences. Choice D is incorrect because providing care based solely on the values of the professional health care system may not consider the cultural diversity of the patient population.
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patients family and friends?
- A. Your family should likely gather at the bedside in case theres a negative outcome.
- B. Make sure she doesnt eat any food in the 24 hours before the procedure.
- C. Wear a hospital gown when you go into the patients room.
- D. Do not visit if youve had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: Do not visit if you've had a recent infection. This is crucial to prevent the transmission of infections to the patient, who will have a compromised immune system post-HSCT. Family and friends with recent infections can pose a serious risk to the patient's health.
Choice A is incorrect because it instills fear and negativity in the family without providing any tangible benefits.
Choice B is incorrect as fasting is not typically required before a HSCT and can be harmful to the patient's nutritional status.
Choice C is incorrect as wearing a hospital gown is generally not necessary for visitors, unless specified by the healthcare team for infection control purposes.