Nokea
A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene?
- A. Custard
- B. Frozen yogurt
- C. Pureed vegetables
- D. Mashed potatoes and gravy
Correct Answer: D
Rationale: Mashed potatoes and gravy are not appropriate for a full liquid diet. A full liquid diet consists of foods that are liquid at room temperature or melt into liquid form at body temperature. Mashed potatoes and gravy are not in liquid form and therefore should not be consumed by a patient following a full liquid diet. The nurse should intervene and provide education about the correct food choices allowed on a full liquid diet, such as custard, frozen yogurt, and pureed vegetables.
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A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an increase in the patients abdominal girth and the patient complains of bloating. What is the nurses most appropriate action?
- A. Provide the patient with an unsweetened, carbonated beverage.
- B. Apply warm compresses to the patients lower abdomen.
- C. Provide an ice pack to apply to the perineum and suprapubic region.
- D. Assist the patient into a prone position.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take in this situation is to apply warm compresses to the patient's lower abdomen. Abdominal bloating and an increase in abdominal girth can be common following a vaginal hysterectomy. Applying warm compresses to the lower abdomen can help to relieve bloating and discomfort by promoting relaxation of the abdominal muscles and increasing blood flow to the area. This can provide relief to the patient and support their recovery process. Applying warm compresses is a non-invasive intervention that can be easily implemented and is commonly used in post-operative care to address abdominal discomfort.
A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim?
- A. To prioritize emotional needs
- B. To prevent and relieve suffering
- C. To bridge between curative care and hospice care
- D. To provide care while there is still hope
Correct Answer: B
Rationale: The primary aim when transitioning a patient with rapid cancer metastases from active treatment to palliative care is to prevent and relieve suffering. Palliative care focuses on enhancing quality of life, managing symptoms, and addressing physical, emotional, and spiritual needs. By prioritizing the prevention and relief of suffering, healthcare providers can work towards improving the patient's comfort and overall well-being during this difficult time. This approach aligns with the goals of palliative care, which aim to provide holistic support and care for patients facing serious illnesses like cancer.
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 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. A nonmobile mass with irregular edges
- C. A mobile mass that is soft and easily delineated
- D. Nonpalpable right axillary lymph nodes
Correct Answer: B
Rationale: A nonmobile mass with irregular edges would most strongly suggest that the patient's lump is cancerous. Breast cancer lumps typically do not move easily and have irregular, poorly defined edges. These characteristics are concerning because they can indicate an invasive and aggressive growth pattern. Additionally, the fact that the lump is painless is another feature that raises suspicion for malignancy. It is important for the patient to undergo further evaluation, possibly including a mammogram, ultrasound, and biopsy, to determine the nature of the lump and provide appropriate treatment.
A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?
- A. Closely monitoring the input and output of the bladder irrigation system
- B. Administering parenteral nutrition and fluids as ordered
- C. Monitoring the patients level of consciousness and skin turgor
- D. Scanning the patients bladder for retention every 2 hours
Correct Answer: A
Rationale: The nurse should prioritize closely monitoring the input and output of the bladder irrigation system to assess for the risk of imbalanced fluid volume in a patient following a transuretheral resection of the prostate. Bladder irrigation is a common postoperative procedure used to prevent blood clots and help with healing. Monitoring the input and output of the bladder irrigation system is crucial in assessing the patient's fluid balance. Changes in the output may indicate bleeding or retention, which can lead to imbalanced fluid volume. By closely monitoring the bladder irrigation system, the nurse can promptly identify any issues and intervene accordingly to prevent further complications. Monitoring the patient's level of consciousness, skin turgor, and scanning for bladder retention are important assessments, but for this specific situation, monitoring the bladder irrigation system is the priority to assess for imbalanced fluid volume.