Nokea
A patient has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation system in place. The patient tells you he is experiencing bladder spasms and asks what you can do to relieve his discomfort. What is the most appropriate nursing action to relieve the discomfort of the patient?
- A. Apply a cold compress to the pubic area.
- B. Notify the urologist promptly.
- C. Irrigate the catheter with 30 to 50 mL of normal saline as ordered.
- D. Administer a smooth-muscle relaxant as ordered.
Correct Answer: D
Rationale: Rationale: Administering a smooth-muscle relaxant is the most appropriate nursing action to relieve bladder spasms post-TURP. The smooth-muscle relaxant helps relax the bladder muscles, reducing spasms and discomfort. Applying a cold compress (choice A) may provide temporary relief but won't address the underlying cause. Notifying the urologist (choice B) is important but not the immediate action for relieving spasms. Irrigating the catheter with normal saline (choice C) may not effectively address the spasms. Administering a smooth-muscle relaxant is the best choice for prompt relief.
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The hospice nurse has just admitted a new patient to the program. What principle guides hospice care?
- A. Care addresses the needs of the patient as well as the needs of the family.
- B. Care is focused on the patient centrally and the family peripherally.
- C. The focus of all aspects of care is solely on the patient.
- D. The care team prioritizes the patients physical needs and the family is responsible for the patients emotional needs.
Correct Answer: A
Rationale: The correct answer is A because hospice care is centered on a holistic approach that considers the physical, emotional, social, and spiritual needs of both the patient and their family. This principle recognizes that caring for a terminally ill patient involves supporting the entire family unit. Choice B is incorrect because family support is integral to hospice care. Choice C is incorrect because hospice care extends beyond just the patient to include their loved ones. Choice D is incorrect because the care team should address all aspects of care for both the patient and their family, not prioritize one over the other.
A patient is receiving opioids for pain. Which bowel assessment is a priority?
- A. Clostridium difficile
- B. Constipation
- C. Hemorrhoids
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications.
Incorrect choices:
A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use.
C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment.
D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.
A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
- A. Position the patient in the high Fowlers position whenever possible.
- B. Temporarily eliminate animal protein from the patients diet.
- C. Make sure the patient eats at least two servings of raw fruit each day.
- D. Obtain a stool culture to identify possible pathogens.
Correct Answer: D
Rationale: The correct answer is D: Obtain a stool culture to identify possible pathogens. This is the most appropriate nursing intervention because chronic diarrhea in a patient with AIDS can be caused by various pathogens such as parasites, bacteria, or viruses. By obtaining a stool culture, the healthcare team can identify the specific pathogen responsible for the diarrhea and initiate targeted treatment.
A: Positioning the patient in the high Fowler's position is not directly related to addressing the underlying cause of chronic diarrhea in this patient.
B: Temporarily eliminating animal protein from the patient's diet may not be necessary or effective in treating chronic diarrhea without knowing the specific cause identified through stool culture.
C: Making sure the patient eats raw fruit is not recommended as raw fruits can sometimes worsen diarrhea due to their high fiber content and potential for carrying pathogens.
In summary, obtaining a stool culture is the most appropriate intervention as it helps identify the specific pathogen causing the diarrhea, while the other options do not directly address the underlying cause.
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
- A. Reassure the patient that she will still be able to have children.
- B. Reassure the patient that she does not have to have sex to be feminine.
- C. Reassure the patient that you know how she is feeling and that you feel her anxiety and pain.
- D. Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm.
Correct Answer: B
Rationale: The correct answer is B: Reassure the patient that she does not have to have sex to be feminine.
Rationale:
1. Acknowledges patient's feelings: By reassuring the patient that she does not have to have sex to be feminine, the nurse validates the patient's emotions and concerns.
2. Addresses societal norms: This intervention challenges societal stereotypes that equate femininity solely with reproductive capabilities.
3. Promotes self-acceptance: Encouraging the patient to embrace her femininity beyond physical aspects fosters self-acceptance and self-worth.
4. Supports holistic care: Recognizing the multifaceted nature of femininity shows a holistic approach to addressing the patient's body image issues.
Summary:
A, C, and D are incorrect as they do not directly address the patient's specific concerns about her body image and femininity. Choice B is the most appropriate intervention as it validates the patient's feelings and challenges societal norms, promoting self-acceptance and holistic care
You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer?
- A. Palliative
- B. Reconstructive
- C. Salvage
- D. Prophylactic
Correct Answer: A
Rationale: The correct answer is A: Palliative surgery. In this scenario, the patient's colon cancer has already progressed to stage IV with metastasis to the liver, indicating an advanced and incurable condition. Palliative surgery aims to alleviate symptoms, improve quality of life, and prolong survival without aiming for a cure. Reconstructive surgery (B) is typically done to restore form or function, which is not the primary goal in this case. Salvage surgery (C) is usually performed to rescue a situation where initial treatment has failed, which is not the case here. Prophylactic surgery (D) is preventive and is not appropriate in a situation where cancer is already present and advanced.