Nokea
A patient has just been told that her illness is terminal. The patient tearfully states, I cant believe I am going to die. Why me? What is your best response?
- A. I know how you are feeling.
- B. You have lived a long life.
- C. This must be very difficult for you.
- D. Life can be so unfair.
Correct Answer: C
Rationale: The correct answer is C: "This must be very difficult for you." This response acknowledges the patient's emotional state and shows empathy without making assumptions or dismissing their feelings. It validates the patient's emotions and opens up the opportunity for further discussion or support.
Rationale:
1. A: "I know how you are feeling" assumes the tutor knows the exact emotions of the patient, which can come off as insincere or dismissive.
2. B: "You have lived a long life" does not address the patient's emotional distress or provide comfort in the face of a terminal illness.
3. D: "Life can be so unfair" does not directly address the patient's feelings and may come off as generic or cliché.
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A nurse is charting on a patient’s record. Whichaction will the nurse take that is accurate legally?
- A. Charts legibly
- B. States the patient is belligerent
- C. Writes entry for another nurse
- D. Uses correction fluid to correct error
Correct Answer: A
Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues.
Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient. Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences. Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?
- A. Assessing for mouth droop and decreased lateral eye gaze
- B. Assessing for increased middle ear pressure and perforated ear drum
- C. Assessing for gradual onset of conductive hearing loss and nystagmus
- D. Assessing for scar tissue and cerumen obstructing the auditory canal
Correct Answer: A
Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications.
Choices B, C, and D are incorrect:
B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient.
C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively.
D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.
A patient has just returned to the postsurgical unit from post-anesthetic recovery after breast surgery for removal of a malignancy. What is the most likely major nursing diagnosis to include in this patients immediate plan of care?
- A. Acute pain related to tissue manipulation and incision
- B. Ineffective coping related to surgery
- C. Risk for trauma related to post-surgical injury
- D. Chronic sorrow related to change in body image
Correct Answer: A
Rationale: The correct answer is A: Acute pain related to tissue manipulation and incision. This is the most likely major nursing diagnosis because post-surgical pain is a common and expected occurrence after breast surgery. The patient is likely to experience pain due to tissue manipulation and incision during the surgery. Addressing acute pain is crucial for the patient's comfort, well-being, and overall recovery.
Choice B (Ineffective coping related to surgery) may be a secondary nursing diagnosis, but acute pain takes priority as it directly impacts the patient's immediate comfort and recovery. Choice C (Risk for trauma related to post-surgical injury) is not the most appropriate nursing diagnosis since the patient has already undergone surgery and is not at risk for further injury at this point. Choice D (Chronic sorrow related to change in body image) is not the most immediate concern post-surgery; addressing acute pain is more critical.
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
- A. Have the patient void and have bowel movements using a commode rather than toilet.
- B. Count and inspect each perineal pad that the patient uses.
- C. Swab the patients perineum for the presence of blood at least once per shift.
- D. Leave the patients perineum open to air to facilitate inspection.
Correct Answer: B
Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage.
A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring.
C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads.
D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.
A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?
- A. Acute Abdominal Pain
- B. Diarrhea
- C. Bowel Incontinence
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Diarrhea. In stage 3 HIV, gastrointestinal issues are common due to weakened immune system. Diarrhea can lead to dehydration and electrolyte imbalances, making it the priority nursing diagnosis. Acute Abdominal Pain (A) may be a symptom but not the priority. Bowel Incontinence (C) and Constipation (D) are less likely in stage 3 HIV.