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A patient has fallen several times in the pastweek when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse ismostappropriate in correcting this urinaryproblem?
- A. Limit fluid and caffeine intake before bed.
- B. Leave the bathroom light on to illuminate a pathway.
- C. Practice Kegel exercises to strengthen bladder muscles.
- D. Clear the path to the bathroom of all obstacles before bedtime.
Correct Answer: A
Rationale: The correct answer is A: Limit fluid and caffeine intake before bed. This recommendation addresses the issue of nocturia (frequent urination at night) by reducing the amount of urine produced before bedtime, therefore decreasing the need to get up during the night. Caffeine is a diuretic, so limiting its intake can also help reduce the frequency of urination. Choices B, C, and D do not directly address the underlying cause of nocturia and falling. Leaving the bathroom light on (choice B) may help with visibility but does not address the urinary problem. Kegel exercises (choice C) focus on pelvic floor muscles, not bladder muscles. Clearing the path to the bathroom (choice D) can prevent falls but does not address the urinary issue.
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The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
- A. Aggressively continuing to fight the disease process
- B. Moving the patient to a long-term care facility when it becomes necessary
- C. Including the children in planning their fathers care
- D. Supporting the patients and familys values and choices
Correct Answer: D
Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.
A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
- A. Evaluate the patients milk production.
- B. Palpate the area for a breast mass.
- C. Assess the patients knowledge of breast cancer.
- D. Assure the patient that this likely an age-related change.
Correct Answer: B
Rationale: The correct answer is B. Palpating the area for a breast mass is the most appropriate assessment in this scenario as dimpling of the breast can be a sign of underlying breast abnormalities such as a mass or tumor. By palpating the area, the nurse can determine if there is a lump or any other irregularity that may require further investigation.
Choice A is incorrect because evaluating the patient's milk production is not relevant to the presenting symptom of breast dimpling.
Choice C is incorrect as assessing the patient's knowledge of breast cancer does not address the immediate need for a physical assessment of the breast dimpling.
Choice D is incorrect because assuming that the dimpling is just an age-related change without further assessment could delay potential diagnosis and treatment of a serious condition.
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
- A. Interrupted sleep pattern
- B. Hot flashes
- C. Epistaxis (nose bleed)
- D. Increased weight
Correct Answer: C
Rationale: The correct answer is C: Epistaxis (nose bleed). Thrombocytopenia is a condition characterized by a low platelet count, leading to impaired blood clotting and an increased risk of bleeding. Epistaxis is a common symptom of thrombocytopenia due to the lack of platelets to aid in clot formation. Assessing for epistaxis in patients receiving carmustine is crucial to monitor and manage potential bleeding complications. Choices A, B, and D are incorrect as they are not directly associated with thrombocytopenia.
The nurse in an allergy clinic is educating a new patient about the pathology of the patients health problem. What response should the nurse describe as a possible consequence of histamine release?
- A. Constriction of small venules
- B. Contraction of bronchial smooth muscle
- C. Dilation of large blood vessels
- D. Decreased secretions from gastric and mucosal cells
Correct Answer: B
Rationale: The correct answer is B: Contraction of bronchial smooth muscle. Histamine release can lead to bronchoconstriction, which narrows the airways and causes difficulty in breathing. This is a common symptom in allergic reactions like asthma. Constriction of small venules (Choice A) is not a typical consequence of histamine release. Dilation of large blood vessels (Choice C) is more associated with histamine's role in increasing vascular permeability. Decreased secretions from gastric and mucosal cells (Choice D) is not directly related to histamine's effects on smooth muscle contraction.
A patient has been diagnosed with polycystic ovary syndrome (PCOS). The nurse should encourage what health promotion activity to address the patients hormone imbalance and infertility?
- A. Kegel exercises
- B. Increased fluid intake
- C. Weight loss
- D. Topical antibiotics as ordered
Correct Answer: C
Rationale: The correct answer is C: Weight loss. In PCOS, weight loss can help improve hormone balance and fertility by reducing insulin resistance and regulating hormone levels. Excess weight can exacerbate symptoms of PCOS. Kegel exercises (A) are beneficial for pelvic floor strength but do not directly address hormone imbalance. Increased fluid intake (B) is important for overall health but does not specifically target hormone imbalance. Topical antibiotics (D) are unrelated to PCOS treatment.