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A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurses most appropriate action?
- A. Reassure the patient that this is an age-related change in vision.
- B. Arrange for the patient to have her visual acuity assessed.
- C. Arrange for the patient to be assessed for macular degeneration.
- D. Facilitate tonometry testing.
Correct Answer: C
Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.
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The nurse is caring for a patient who has been recently diagnosed with late stage pancreatic cancer. The patient refuses to accept the diagnosis and refuses to adhere to treatment. What is the most likely psychosocial purpose of this patients strategy?
- A. The patient may be trying to protect loved ones from the emotional effects of the illness.
- B. The patient is being noncompliant in order to assert power over caregivers.
- C. The patient may be skeptical of the benefits of the Western biomedical model of health.
- D. The patient thinks that treatment does not provide him comfort.
Correct Answer: A
Rationale: The patient may be trying to protect loved ones from the emotional effects of the illness. This behavior could be a form of denial, a defense mechanism where the individual refuses to acknowledge the reality of the diagnosis in order to shield their loved ones from distress. By rejecting the diagnosis and refusing treatment, the patient may believe that they are preventing their family and friends from experiencing the emotional pain associated with the illness. This behavior is a common coping mechanism in response to overwhelming and distressing news like a terminal illness diagnosis. It serves a psychosocial purpose of trying to protect others from suffering, even though it may not align with the patient's best interest in terms of receiving appropriate medical care.
A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment?
- A. Loss of hearing, tinnitus, and vertigo
- B. Loss of vision, change in mental status, and hyperthermia
- C. Loss of hearing, increased sodium retention, and hypertension
- D. Loss of vision, headache, and tachycardia
Correct Answer: A
Rationale: A nurse assessing a patient with an acoustic neuroma would likely find symptoms such as loss of hearing, tinnitus, and vertigo. Acoustic neuroma, also known as vestibular schwannoma, is a noncancerous tumor that develops on the vestibulocochlear nerve, which carries sound and balance signals from the inner ear to the brain. The most common symptoms of an acoustic neuroma include progressive hearing loss, ringing in the ears (tinnitus), and dizziness or imbalance (vertigo). Therefore, option A is the most appropriate choice for the symptoms that the nurse is likely to find in a patient with an acoustic neuroma.
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
- A. Teach the patient about the risks of ototoxic medications.
- B. Instruct the patient to protect the ear from water for several weeks.
- C. Teach the patient to remove cerumen safely at least once per week.
- D. Instruct the patient to protect the ear from temperature extremes until healing is complete.
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.
The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse?
- A. A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away.
- B. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.
- C. A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away.
- D. A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.
Correct Answer: A
Rationale: A person whose vision is measured at 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. In this measurement system, the first number represents how far away the person is from the eye chart (the testing distance), and the second number indicates how far away a person with normal vision can be from the chart to see the same line of letters or objects. Therefore, if someone has 20/40 vision, it means they need to be at 20 feet to see what a person with 20/20 vision can see at 40 feet.
A preceptor is working with a new nurse on documentation.Which situation will cause the preceptor to follow up?
- A. The new nurse documents only for self.
- B. The new nurse charts consecutively on every other line.
- C. The new nurse ends each entry with signature and title.
- D. The new nurse keeps the password secure.
Correct Answer: B
Rationale: The preceptor would need to follow up with the new nurse for charting consecutively on every other line. This behavior is incorrect as it can lead to confusion and potential errors in documentation. Correct charting practice involves documenting consecutively, line by line without skipping lines in between. The preceptor should provide guidance and correction to ensure accurate and organized documentation for patient care.