Nokea
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.
You may also like to solve these questions
Which finding would indicate concealed hemorrhage in abruptio placentae?
- A. Bradycardia
- B. Hard boardlike abdomen
- C. Decrease in fundal height
- D. Decrease in abdominal pain
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention.
Rationale:
A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae.
C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage.
D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patients tumor, the nurse should implement measures to prevent what complication?
- A. Falls
- B. Audio hallucinations
- C. Respiratory depression
- D. Labile BP
Correct Answer: A
Rationale: The correct answer is A: Falls. A cerebellar tumor can affect coordination and balance, leading to an increased risk of falls. Measures to prevent falls include maintaining a clutter-free environment, using assistive devices, and providing supervision.
Choice B (Audio hallucinations) is incorrect as cerebellar tumors typically do not cause auditory hallucinations. Choice C (Respiratory depression) is incorrect as cerebellar tumors do not directly affect the respiratory system. Choice D (Labile BP) is incorrect as cerebellar tumors are not typically associated with blood pressure fluctuations.
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 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurses best response?
- A. Theres no way to be sure you wont get HIV except to use condoms correctly.
- B. Only the correct use of a female condom protects against the transmission of HIV.
- C. There are new ways of protecting yourself from HIV that are being discovered every day.
- D. Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.
Correct Answer: D
Rationale: The correct answer is D because it emphasizes the importance of consistent and correct condom use in preventing HIV transmission. Here's the rationale:
1. Abstinence is the most effective way to prevent HIV, but since the teen is sexually active, abstinence may not be feasible for her.
2. Using condoms consistently and correctly is the next best method for preventing HIV transmission during sexual activity.
3. Choice A is incorrect because it implies that using condoms is not effective, which is not true.
4. Choice B is incorrect because it only mentions female condoms, while both male and female condoms can be effective in preventing HIV.
5. Choice C is incorrect because while new prevention methods are being researched, the established method of consistent condom use remains the most effective.
A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The patient states, They tell me my cancer is malignant, while my coworkers breast tumor was benign. I just dont understand at all. When preparing a response to this patient, the nurse should be cognizant of what characteristic that distinguishes malignant cells from benign cells of the same tissue type?
- A. Slow rate of mitosis of cancer cells
- B. Different proteins in the cell membrane
- C. Differing size of the cells
- D. Different molecular structure in the cells
Correct Answer: D
Rationale: The correct answer is D: Different molecular structure in the cells. Malignant cells have alterations in their molecular structure, leading to uncontrolled growth and invasion of surrounding tissues, while benign cells retain their normal molecular structure and do not invade nearby tissues. This distinction is crucial in understanding why malignant cells are cancerous and pose a greater risk compared to benign cells.
Other choices are incorrect because:
A: Slow rate of mitosis of cancer cells - Malignant cells actually have a rapid rate of mitosis, contributing to their uncontrolled growth.
B: Different proteins in the cell membrane - While there may be differences in proteins, the molecular structure is a more fundamental difference between malignant and benign cells.
C: Differing size of the cells - Cell size alone is not a definitive characteristic that distinguishes between malignant and benign cells; molecular structure plays a more significant role.