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A patient requests the nurse’s help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient’s inability to void?
- A. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.
- B. The patient does not recognize the physiological signals that indicate a need to void.
- C. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention.
- D. The patient is not drinking enough fluids to produce adequate urine output.
Correct Answer: A
Rationale: The correct answer is A: The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.
Rationale: Anxiety can lead to tension in the abdominal and perineal muscles, inhibiting the ability to relax and urinate. The sympathetic nervous system response to anxiety can cause urinary retention. So, the patient's frustration in voiding in front of the nurse may be due to anxiety hindering muscle relaxation.
Summary of other choices:
B: The patient not recognizing physiological signals is less likely as the patient requested assistance to void, indicating awareness of the need to urinate.
C: The patient being lonely and seeking attention is not relevant to the inability to void in front of the nurse.
D: Inadequate fluid intake may contribute to decreased urine output but is not directly related to the inability to void in front of the nurse.
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A nurse wants to find the daily weights of apatient. Which form will the nurse use?
- A. Database
- B. Progress notes
- C. Patient care summary
- D. Graphic record and flow sheet
Correct Answer: D
Rationale: The correct answer is D: Graphic record and flow sheet. The nurse will use a graphic record and flow sheet to document the patient's daily weights. This form allows for easy tracking and visualization of weight trends over time. Database (A) is used for storing large amounts of data but not ideal for daily weight tracking. Progress notes (B) are for narrative descriptions of patient care, not specific for daily weights. Patient care summary (C) provides an overview of the patient's care plan, not detailed daily weights.
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
- A. Hypoglycemia
- B. Hypercalcemia
- C. Hypoinsulinemia
- D. Hypobilirubinemia
Correct Answer: A
Rationale: The correct answer is A: Hypoglycemia. Infants of diabetic mothers are at risk for hypoglycemia due to excessive insulin production in response to high glucose levels in utero. Monitoring blood glucose levels is crucial to prevent hypoglycemia-related complications.
B: Hypercalcemia is not a major neonatal complication seen in infants of diabetic mothers.
C: Hypoinsulinemia refers to low levels of insulin, which is not typically a concern in infants of diabetic mothers.
D: Hypobilirubinemia is not a common complication in infants of diabetic mothers.
In summary, monitoring for hypoglycemia is essential in infants of diabetic mothers to prevent potential complications.
The nurse is teaching a health class about thegastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients?
- A. Ileum
- B. Cecum
- C. Stomach
- D. Duodenum
Correct Answer: D
Rationale: The correct answer is D: Duodenum. The duodenum is the first part of the small intestine where most of the digestion and absorption of nutrients occurs. It receives partially digested food from the stomach and mixes it with bile and pancreatic enzymes to break down nutrients. The villi in the duodenum increase the surface area for absorption. The other choices (A: Ileum, B: Cecum, C: Stomach) are incorrect because the ileum and cecum are parts of the small intestine where some absorption occurs but not as much as in the duodenum. The stomach primarily digests food and does not absorb many nutrients.
The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The childs mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the childs pain and suffering. What intervention has the highest priority?
- A. Allowing the patient to express her feelings without judging her
- B. Helping the patient to understand the phases of the grieving process
- C. Reassuring the patient that the childs death is not her fault
- D. Arranging for genetic counseling to inform the patient of her chances of having another child with the disease
Correct Answer: A
Rationale: The correct answer is A: Allowing the patient to express her feelings without judging her. This intervention has the highest priority as it focuses on providing emotional support and creating a safe space for the mother to express her emotions without feeling judged. In this situation, the mother is experiencing intense guilt and grief, and allowing her to talk about her feelings can help her process her emotions and cope with the impending loss. By listening actively and without judgment, the nurse can demonstrate empathy and compassion, which are crucial in supporting the mother through this difficult time.
Summary:
B: Helping the patient to understand the phases of the grieving process may be helpful, but it is not the highest priority at this moment.
C: Reassuring the patient that the child's death is not her fault is important, but the priority is to address the mother's emotional needs first.
D: Arranging for genetic counseling is not the highest priority at this time as the immediate focus should be on providing emotional support to the mother
A 67-year-old woman experienced the death of her husband from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the woman will be going through the process of mourning for an extended period of time. What processes of mourning will allow the woman to accommodate the loss in a healthy way? Select all that apply.
- A. Reiterating her anger at her husbands care team
- B. Reinvesting in new relationships at the appropriate time
- C. Reminiscing about the relationship she had with her husband
- D. Relinquishing old attachments to her husband at the appropriate time E) Renewing her lifelong commitment to her husband
Correct Answer: B
Rationale: The correct answer is B: Reinvesting in new relationships at the appropriate time. This process of mourning involves the woman gradually shifting her focus from the past relationship with her husband to forming new relationships or reinvesting in existing ones. This is crucial for her to adapt to life without her husband and move forward in a healthy manner.
A: Reiterating her anger at her husband's care team is not a healthy process as it can lead to prolonged resentment and hinder the mourning process.
C: Reminiscing about the relationship she had with her husband is a natural part of mourning but solely focusing on reminiscing may not allow her to fully adapt to life without her husband.
D: Relinquishing old attachments to her husband at the appropriate time is important, but it is only one aspect of the mourning process. It is not the sole process necessary for healthy mourning.
E: Renewing her lifelong commitment to her husband is not a healthy process as it prevents her from accepting the loss and