Nokea
A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Mnires disease. What question is it most important for the nurse to ask the patient in preparation for this test?
- A. Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces?
- B. Do you currently take any tranquilizers or stimulants on a regular basis?
- C. Do you have a history of falls or problems with loss of balance?
- D. Do you have a history of either high or low blood pressure?
Correct Answer: A
Rationale: The correct answer is A: Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? This question is important because electronystagmography involves the patient being placed in a confined space with sensors attached to monitor eye movements. Claustrophobia or anxiety can significantly impact the patient's ability to tolerate the test, affecting its accuracy.
Choice B: Do you currently take any tranquilizers or stimulants on a regular basis? While relevant in some cases, it is not as crucial as ensuring the patient can tolerate the test environment.
Choice C: Do you have a history of falls or problems with loss of balance? While relevant to Mnire's disease, it is not directly related to the preparation for electronystagmography.
Choice D: Do you have a history of either high or low blood pressure? While monitoring blood pressure is important for some procedures, it is not a primary concern for electronystagmography.
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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 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated that he requires surgery, stating that it will leave him emasculated and a shell of a man. The nurse should identify what nursing diagnosis when planning the patients subsequent care?
- A. Disturbed Body Image Related to Effects of Surgery
- B. Spiritual Distress Related to Effects of Cancer Surgery
- C. Social Isolation Related to Effects of Surgery
- D. Risk for Loneliness Related to Change in Self-Concept
Correct Answer: A
Rationale: The correct answer is A: Disturbed Body Image Related to Effects of Surgery. This nursing diagnosis is appropriate because the patient expresses concerns about feeling emasculated and a shell of a man after the surgery, indicating a disturbance in his body image. The patient's perception of how the surgery will affect his masculinity is a clear indication of body image disturbance.
Choice B is incorrect because there is no mention of spiritual distress in the patient's statements. Choice C is incorrect as there is no indication that the patient will experience social isolation specifically related to the surgery. Choice D is incorrect as the patient's concerns are primarily related to his body image and not loneliness.
The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?
- A. Provide small, frequent nutrient-dense meals for maximizing kilocalories.
- B. Prepare hot meals because they are more easily tolerated by the patient.
- C. Avoid salty foods and limit liquids to preserve electrolytes.
- D. Encourage intake of fatty foods to increase caloric intake.
Correct Answer: A
Rationale: The correct answer is A because providing small, frequent nutrient-dense meals helps maximize kilocalories, which is important for patients with AIDS who may have difficulty maintaining weight due to their compromised immune system. This approach ensures the patient receives essential nutrients and energy to support their immune function.
Choice B is incorrect as there is no evidence to suggest that hot meals are more easily tolerated by AIDS patients.
Choice C is incorrect because limiting liquids can lead to dehydration, which is especially detrimental for individuals with weakened immune systems.
Choice D is incorrect as encouraging the intake of fatty foods may not necessarily provide the necessary nutrients and energy required for immune support in AIDS patients.
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.
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
- A. Herpes simplex
- B. HIV
- C. Spina bifida
- D. Hypogammaglobulinemia
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems.
Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies.
Choice B: HIV weakens the immune system but is not specifically associated with latex allergies.
Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.