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A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patients discharge education?
- A. Expected changes in facial nerve function
- B. The need for audiometry testing every 6 months following recovery
- C. Safe use of analgesics and antivertiginous agents
- D. Appropriate use of OTC ear drops
Correct Answer: C
Rationale: Step 1: After mastoid surgery, patients may experience pain and dizziness, hence addressing the safe use of analgesics and antivertiginous agents is crucial for symptom management.
Step 2: Analgesics help in managing post-operative pain, while antivertiginous agents help control dizziness, reducing the risk of falls.
Step 3: Educating the patient on safe use ensures proper pain and symptom management, preventing complications.
Step 4: Other choices are incorrect as they do not directly address immediate post-operative care needs such as pain and dizziness management.
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A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
- A. “I know I will need to have an abortion as soon as possible.”
- B. “Even though my test is positive, my baby might not be affected.”
- C. “My baby is certain to have AIDS and die within the first year of life.”
- D. “This pregnancy will probably decrease the chance that I will develop AIDS.”
Correct Answer: B
Rationale: The correct answer is B because it shows an understanding that being HIV-positive does not guarantee transmission to the baby. The statement acknowledges the possibility of the baby not being affected, which demonstrates awareness of the varying outcomes. Choice A is incorrect as it assumes abortion is the only option. Choice C is incorrect as it makes an extreme and inaccurate claim. Choice D is incorrect as pregnancy does not decrease the chance of developing AIDS.
Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
- A. Increasing fluid intake
- B. Dribbling of urine
- C. Voiding in small amounts
- D. Voiding within 6 hours of catheter removal
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection.
A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal.
C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem.
D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.
The nurse is teaching a health class about theChooseMyPlateprogram. Which guidelines will thenurse include in the teaching session?
- A. Balancing sodium and potassium
- B. Decreasing water consumption
- C. Increasing portion size
- D. Balancing calories
Correct Answer: D
Rationale: The correct answer is D, balancing calories. This is because the ChooseMyPlate program emphasizes the importance of maintaining a balance between the calories consumed and calories expended for overall health and weight management. By balancing calories, individuals can ensure they are meeting their nutritional needs without overeating or consuming excess calories.
A: Balancing sodium and potassium is important for managing blood pressure, but this is not a specific guideline of the ChooseMyPlate program.
B: Decreasing water consumption is not a guideline of the ChooseMyPlate program. Adequate hydration is essential for overall health.
C: Increasing portion size is not recommended in the ChooseMyPlate program. It emphasizes portion control and eating appropriate serving sizes of different food groups.
A nurse is performing a cultural assessment usingthe ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”?
- A. Health
- B. Healers
- C. History
- D. Homeland
Correct Answer: B
Rationale: The correct answer is B: Healers. In the ETHNIC mnemonic, "H" stands for Healers, where the nurse assesses the individual's traditional healers, healthcare practices, and preferences for seeking healthcare. This is important in understanding the individual's cultural beliefs and practices related to health and treatment. Assessing "Health" (A) may be important, but it does not specifically address traditional healers. "History" (C) focuses on the individual's cultural background rather than healthcare practices. "Homeland" (D) pertains to the individual's place of origin, which is not directly related to healthcare communication.
A nurse is caring for a patient with a continenturinary reservoir. Which action will the nurse take?
- A. Teach the patient how to self-cath the pouch.
- B. Teach the patient how to perform Kegel exercises.
- C. Teach the patient how to change the collection pouch.
- D. Teach the patient how to void using the Valsalva technique. In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using a Valsalva technique. In a ureterostomy or ileal conduit the patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. Kegel exercises are ineffective for a patient with a continent urinary reservoir.
Correct Answer: A
Rationale: The correct answer is A: Teach the patient how to self-cath the pouch. In a continent urinary reservoir, patients need to catheterize the pouch several times a day. This is essential for emptying the urine from the pouch as the ileocecal valve creates a one-way valve. Teaching the patient how to self-catheterize ensures proper and timely drainage, preventing complications like urinary retention. Self-catheterization also empowers the patient to take an active role in managing their continence.
Summary of other choices:
B: Kegel exercises are ineffective for a patient with a continent urinary reservoir as they do not address the need for catheterization.
C: Changing the collection pouch is not the primary action needed for a continent urinary reservoir. Catheterization is essential for drainage.
D: The Valsalva technique is not appropriate for voiding in a continent urinary reservoir. Catheterization is the recommended method for emptying the pouch.