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A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?
- A. Explain the location of items using clock cues.
- B. Explain that each of the items on the tray is clearly separated.
- C. Describe the location of items from the bottom of the plate to the top.
- D. Ask the patient to describe the location of items before confirming their location.
Correct Answer: A
Rationale: The correct answer is A because using clock cues helps the patient visualize the placement of items based on a familiar concept. This aids in compensating for the loss of vision after head trauma. Choice B does not provide specific guidance on how to describe the placement. Choice C may be confusing for the patient as it is not a common way to describe item placement. Choice D puts unnecessary burden on the patient to describe the location first before confirming, which may be challenging for someone with sudden loss of vision.
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A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurses best response?
- A. I can only imagine how you feel. Would you like to talk about it?
- B. Lets find a quiet spot and Ill teach you a few coping strategies.
- C. Thats the same way that most patients who have a chronic illness feel.
- D. Do you think that maybe you could be managing things more efficiently?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship.
Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.
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.
In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide?
- A. Supplement breast milk with corn syrup.
- B. Give cow’s milk during the first year of life.
- C. Add honey to infant formulas for increased energy.
- D. Provide breast milk or formula for the first 4 to 6 months.
Correct Answer: D
Rationale: The correct answer is D because breast milk or formula is recommended for the first 4 to 6 months as it provides essential nutrients for infant growth and development. Choosing A, B, or C is incorrect as they pose health risks to infants - corn syrup is not necessary, cow's milk is not suitable for infants, and honey can cause botulism in infants under 1 year old. Breast milk or formula is the safest and most nutritionally balanced option for infants in the first few months of life.
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.
The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify?
- A. Helping the family to understand why the patient needs to be sedated
- B. Making arrangements to promptly move the patient to an acute-care facility
- C. Explaining to the family that death is near and the patient needs around-the-clock nursing care
- D. Teaching family members how to interact with, and ensure safety for, the patient with impaired cognition
Correct Answer: D
Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being.
Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.