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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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A nurse is assessing population groups for therisk of suicide requiring medical attention. Which group should the nurse monitormostclosely?
- A. Young bisexuals
- B. Young caucasians
- C. Asian Americans
- D. African-Americans.
Correct Answer: A
Rationale: Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders. In particular, bisexual youth are at a higher risk than their straight peers for experiencing mental health issues and suicide attempts that require medical attention. Studies have shown that young bisexuals are four times more likely than their straight counterparts to make suicide attempts that necessitate medical intervention. Therefore, it is crucial for the nurse to closely monitor this population group for signs of suicidal behavior and provide the necessary support and interventions to prevent such tragedies.
The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
- A. Cool, clammy skin
- B. Altered sensorium
- C. Pulse oximeter reading of 95%
- D. Respiratory rate of less than 12 breaths per minute
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?
- A. Stopping the administration of the drug immediately
- B. Notifying the patients physician
- C. Continuing the infusion but decreasing the rate
- D. Applying a warm compress to the infusion site .
Correct Answer: A
Rationale: Swelling and pain at the IV site can indicate extravasation, which is the leakage of a vesicant medication like doxorubicin hydrochloride into the surrounding tissues. It is crucial to stop the administration of the drug immediately upon suspicion of extravasation to minimize tissue damage and potential complications. By stopping the administration promptly, further harm can be prevented, and early interventions can be initiated to mitigate the effects of the extravasation. Notifications to the physician and appropriate actions, such as aspiration of any remaining drug, may follow after discontinuing the infusion.
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.
A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?
- A. Administer an antiemetic.
- B. Administer an antimetabolite.
- C. Administer a tumor antibiotic.
- D. Administer an anticoagulant.
Correct Answer: A
Rationale: Nausea and vomiting are common adverse effects of chemotherapy. Administering an antiemetic helps to prevent or reduce these symptoms in patients undergoing chemotherapy. By managing nausea and vomiting, the patient's overall well-being and quality of life during treatment can be improved. Therefore, providing an antiemetic medication is essential in combating these adverse effects and promoting patient comfort and compliance with treatment.