Nokea
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
- A. Interrupted sleep pattern
- B. Hot flashes
- C. Epistaxis (nose bleed)
- D. Increased weight
Correct Answer: C
Rationale: The correct answer is C: Epistaxis (nose bleed). Thrombocytopenia is a condition characterized by a low platelet count, leading to impaired blood clotting and an increased risk of bleeding. Epistaxis is a common symptom of thrombocytopenia due to the lack of platelets to aid in clot formation. Assessing for epistaxis in patients receiving carmustine is crucial to monitor and manage potential bleeding complications. Choices A, B, and D are incorrect as they are not directly associated with thrombocytopenia.
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A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition?
- A. Exostoses
- B. Otalgia
- C. Sensorineural hearing loss
- D. Presbycusis
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. This type of hearing loss is caused by damage to the inner ear or auditory nerve (cranial nerve VIII). Exostoses (A) are bony growths in the ear canal, not related to cranial nerve VIII. Otalgia (B) refers to ear pain, not hearing loss. Presbycusis (D) is age-related hearing loss, not specifically related to damage of the end organ for hearing or cranial nerve VIII. Therefore, C is the most appropriate term to describe the given condition.
Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?
- A. Assessment of pain level
- B. Administration of methotrexate
- C. Administration of Rh immune globulin
- D. Explanation of the common side effects of the treatment plan
Correct Answer: B
Rationale: The correct answer is B: Administration of methotrexate. This is the priority intervention for an intact tubal pregnancy to prevent further growth and potential rupture of the fallopian tube. Methotrexate is a medication used to stop the growth of the pregnancy tissue.
Assessment of pain level (A) is important but not the priority as immediate intervention to address the ectopic pregnancy is crucial.
Administration of Rh immune globulin (C) is not the priority in this situation, as it is typically given after a miscarriage or abortion to prevent Rh sensitization.
Explanation of common side effects (D) is important for patient education, but it is not the immediate priority when dealing with an ectopic pregnancy.
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
- A. Care of the cervical collar
- B. Technique for performing neck ROM exercises
- C. Home assessment of ABGs
- D. Techniques for restoring nerve function
Correct Answer: A
Rationale: Correct Answer: A - Care of the cervical collar
Rationale:
1. Care of the cervical collar is essential post-cervical diskectomy to ensure proper immobilization and support.
2. Proper care prevents complications and promotes healing.
3. It is a crucial aspect of discharge education to prevent injury and promote recovery.
Summary of other choices:
B: Technique for performing neck ROM exercises - Important for rehabilitation but not directly related to discharge education post-cervical diskectomy.
C: Home assessment of ABGs - Irrelevant to post-cervical diskectomy discharge education.
D: Techniques for restoring nerve function - Important for recovery but not a primary focus of discharge education.
The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hypercapnia
- D. Hypocapnia
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin.
Incorrect choices:
B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case.
C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described.
D: Hypocapnia - This is low carbon dioxide levels
A nurse in a long-term care setting that is fundedby Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?
- A. A minimum data set
- B. An admission assessment and acuity level
- C. A focused assessment/specific body system
- D. An intake assessment form and auditing phase
Correct Answer: A
Rationale: The correct answer is A: A minimum data set. In a long-term care setting funded by Medicare and Medicaid, completing standardized protocols for assessment and care planning for reimbursement involves using a minimum data set, which is a standardized instrument for assessing residents' health status. This set of data elements is necessary for comprehensive assessment and care planning to ensure appropriate reimbursement. The other choices (B, C, D) do not specifically address the standardized protocols required for reimbursement in this setting. An admission assessment and acuity level would be part of the process, but not the primary task being completed in this scenario. A focused assessment on a specific body system or an intake assessment form and auditing phase are not synonymous with the standardized protocols needed for reimbursement in a Medicare/Medicaid-funded long-term care facility.