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A patient has just been told she needs to have an incisional biopsy of a right breast mass. During preoperative teaching, how could the nurse best assess this patient for specific educational, physical, or psychosocial needs she might have?
- A. By encouraging her to verbalize her questions and concerns
- B. By discussing the possible findings of the biopsy
- C. By discussing possible treatment options if the diagnosis is cancer
- D. By reviewing her medical history
Correct Answer: A
Rationale: Encouraging the patient to verbalize her questions and concerns is the best way to assess her specific educational, physical, or psychosocial needs during preoperative teaching for an incisional biopsy of a right breast mass. This approach allows the nurse to better understand the patient's knowledge level, fears, anxieties, and any misconceptions she may have related to the procedure. By actively listening to the patient's questions and concerns, the nurse can tailor the education provided to address specific areas of importance to the patient, ensuring she receives the information and support she needs to feel prepared and comfortable before the procedure. This approach promotes open communication, trust, and patient-centered care.
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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.
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.
A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patients room?
- A. That a commode is always available at the bedside
- B. That all furniture remains in the same position
- C. That visitors do not leave items on the bedside table
- D. That the patients slippers stay under the bed
Correct Answer: B
Rationale: It is crucial for the nurse to monitor that all furniture remains in the same position in the hospitalized patient's room. For a patient with impaired vision who needs to create a mental picture of the room to mobilize independently and safely, any changes in the position of furniture can disrupt this mental map and potentially lead to accidents or falls. By ensuring that all furniture remains unchanged, the nurse supports the patient's ability to navigate the room confidently and without obstacles. This monitoring helps promote the patient's safety and independence during their stay in the hospital.
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?
- A. Washing his face
- B. Exposing his skin to sunlight
- C. Using artificial tears
- D. Drinking large amounts of fluids
Correct Answer: A
Rationale: Trigeminal neuralgia is a condition characterized by severe facial pain due to irritation or damage to the trigeminal nerve. Factors such as touching or lightly brushing the face, chewing, speaking, or even encountering a breeze can trigger an attack. Therefore, activities like washing the face that involve touching or stimulating the trigeminal nerve can precipitate an attack in patients with trigeminal neuralgia. It is important for patients to be aware of these triggers to help manage and prevent episodes of pain.
A nurse is teaching a patient about the largeintestine in elimination. In which order will the nurse list the structures, starting with the first portion?
- A. Cecum, ascending, transverse, descending, sigmoid, and rectum
- B. Ascending, transverse, descending, sigmoid, rectum, and cecum
- C. Cecum, sigmoid, ascending, transverse, descending, and rectum
- D. Ascending, transverse, descending, rectum, sigmoid, and cecum
Correct Answer: A
Rationale: The order in which the structures of the large intestine are listed starting with the first portion is as follows: cecum (the pouch where the large intestine begins), ascending colon (runs vertically up the right side of the abdomen), transverse colon (crosses horizontally from the right side of the abdomen to the left), descending colon (descends vertically down the left side of the abdomen), sigmoid colon (the S-shaped curve that leads into the rectum), and rectum (the final portion where feces are stored before being eliminated from the body). Therefore, option A provides the correct order of structures in the large intestine during elimination.