Nokea
A patient presents with a sensation of fullness and pressure in the left ear, along with hearing loss and occasional tinnitus. Otoscopic examination reveals a retracted tympanic membrane with decreased mobility on pneumatic otoscopy. Which of the following conditions is most likely responsible for this presentation?
- A. Acute otitis media
- B. Otitis externa
- C. Serous otitis media (otitis media with effusion)
- D. Cholesteatoma
Correct Answer: C
Rationale: The presentation described in the question (sensation of fullness and pressure in the left ear, hearing loss, occasional tinnitus, retracted tympanic membrane with decreased mobility on pneumatic otoscopy) is suggestive of serous otitis media, also known as otitis media with effusion. Serous otitis media occurs when fluid accumulates in the middle ear without signs of infection. This buildup of fluid in the middle ear space can cause the tympanic membrane to retract and reduce its mobility on pneumatic otoscopy.
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The first standard step in oxygen therapy that the nurse should do is________.
- A. assess client's condition
- B. gather all the equipment and supplies
- C. prepare the client for the oxygen treatment
- D. check the chart for ordered flow rate and oxygen delivery method
Correct Answer: A
Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.
Charting are important documents that are used in court proceedings a Nurse Chona should take note that the following entry recorded would be MOST defensible in court?
- A. Large bruises on thigh upon assessment.
- B. Patient fell out of bed when reaching out for medication.
- C. Burn on the back area observed upon auscultation.
- D. Patient drunk when seen in the Emergency Room.
Correct Answer: A
Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.
During a home visit, a member of the family you're visiting who has been using marijuana for three years tells theyou that he wants to be 'detoxified'. It is important for the nurse to ____.
- A. Instruct the patient to change his lifestyle
- B. Identify the patient's stage of change
- C. Tell the patient that relapses are not tolerated
- D. Realize that the patient is ready for change
Correct Answer: B
Rationale: Identifying the patient's stage of change is crucial when someone expresses a desire to be "detoxified" from a substance like marijuana. The Transtheoretical Model (Stages of Change) outlines different stages individuals go through when making behavior changes. By identifying which stage the patient is in (precontemplation, contemplation, preparation, action, maintenance, or relapse), the nurse can tailor interventions and support accordingly. This approach helps ensure that interventions are effective and appropriate for the individual's readiness for change. It is important to meet the patient where they are in their journey towards detoxification and offer support and guidance accordingly.
A patient with a history of chronic kidney disease is prescribed phosphate binders. Which instruction should the nurse include in patient education about phosphate binder therapy?
- A. "Take phosphate binders with meals."
- B. "Avoid taking phosphate binders with calcium supplements."
- C. "Increase your intake of foods high in phosphorus."
- D. "Take phosphate binders on an empty stomach."
Correct Answer: A
Rationale: The correct instruction that the nurse should include in patient education about phosphate binder therapy is to "Take phosphate binders with meals." Phosphate binders are medications given to patients with chronic kidney disease to help control high phosphate levels in the blood. Taking phosphate binders with meals allows them to bind to the phosphorus present in the food, reducing its absorption in the body. This helps to lower blood phosphate levels effectively. Instructing the patient to take phosphate binders with meals ensures optimal binding of phosphorus from the diet, which is crucial for managing phosphate levels in patients with chronic kidney disease.
A patient with advanced dementia is no longer able to communicate verbally and displays signs of distress. What should the palliative nurse consider when assessing and managing the patient's distress?
- A. Focus solely on physical comfort measures to alleviate distress.
- B. Assume the patient's distress is solely related to physical discomfort.
- C. Explore non-verbal cues and behaviors to identify the underlying causes of distress.
- D. Administer sedative medications to manage the patient's agitation.
Correct Answer: C
Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.