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A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit this patient, what should the nurse assess? Select all that apply.
- A. Adherence to the exercise plan
- B. Overall psychological functioning
- C. Integrity of surgical drains
- D. Understanding of cancer E) Use of the breast prosthesis
Correct Answer: B
Rationale: B. Overall psychological functioning: It is crucial for the home care nurse to assess the patient's overall psychological functioning after a total mastectomy without reconstruction. The patient may be experiencing emotional distress, body image disturbances, anxiety, or depression related to the surgery and changes in physical appearance. The nurse should evaluate the patient's coping mechanisms, emotional well-being, and any signs of psychological implications to provide appropriate support and referral for mental health services if needed.
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Draw up prescribed amount of sterile solution ordered.
- A. 3, 2, 6, 1, 5, 4
- B. 5, 6, 1, 2, 3, 4
- C. 1, 5, 6, 3, 2, 4
- D. 6, 5, 1, 3, 2, 4
Correct Answer: D
Rationale: The correct sequence for drawing up a prescribed amount of sterile solution ordered is as follows: 6, 5, 1, 3, 2, 4.
A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an increase in the patients abdominal girth and the patient complains of bloating. What is the nurses most appropriate action?
- A. Provide the patient with an unsweetened, carbonated beverage.
- B. Apply warm compresses to the patients lower abdomen.
- C. Provide an ice pack to apply to the perineum and suprapubic region.
- D. Assist the patient into a prone position.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take in this situation is to apply warm compresses to the patient's lower abdomen. Abdominal bloating and an increase in abdominal girth can be common following a vaginal hysterectomy. Applying warm compresses to the lower abdomen can help to relieve bloating and discomfort by promoting relaxation of the abdominal muscles and increasing blood flow to the area. This can provide relief to the patient and support their recovery process. Applying warm compresses is a non-invasive intervention that can be easily implemented and is commonly used in post-operative care to address abdominal discomfort.
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.
A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment?
- A. Gag reflex
- B. Deep tendon reflexes
- C. Abdominal girth
- D. Hearing acuity
Correct Answer: A
Rationale: The most critical assessment parameter to include in the initial assessment of a patient with a brain tumor scheduled for surgery is the gag reflex. The gag reflex is a protective mechanism that prevents the entry of foreign objects into the airway and lungs. Patients undergoing brain tumor resection may be at risk for impaired gag reflex due to the effects of the tumor on cranial nerves or related structures. Identifying any impairment in the gag reflex is essential to prevent aspiration during and after the surgical procedure. Monitoring the gag reflex allows the healthcare team to take necessary precautions to protect the patient's airway and prevent complications. Therefore, assessing the gag reflex is crucial in the care of a patient with a brain tumor undergoing surgery.
A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?
- A. Teach the patient guided imagery.
- B. Give the patient more control of her antiretroviral regimen.
- C. Increase the patients activity level.
- D. Collaborate with the patients physician to obtain an order for hydromorphone.
Correct Answer: A
Rationale: The most appropriate nursing intervention for a patient with AIDS experiencing extreme anxiety is to teach the patient guided imagery. Guided imagery is a relaxation technique that can help the patient reduce anxiety levels, promote a sense of calm, and improve overall well-being. By teaching the patient how to use guided imagery, the nurse empowers the patient to manage her anxiety in a non-pharmacological way. This intervention promotes self-care and allows the patient to have a tool to use independently beyond the hospital setting. Giving the patient more control of her antiretroviral regimen may be beneficial for adherence but does not directly address the anxiety symptoms. Increasing the patient's activity level may be helpful for overall well-being but may not specifically target the extreme anxiety. Collaborating with the patient's physician to obtain an order for hydromorphone, a potent opioid medication, is not appropriate unless it is indicated for severe pain management, not anxiety.