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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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The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
- A. Risk for Infection Related to Skin Sloughing
- B. Risk for Acute Pain Related to Loss of Skin Integrity
- C. Risk for Impaired Skin Integrity Related to Cutaneous Lesions
- D. Risk for Impaired Gas Exchange Related to Airway Obstruction
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function.
A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange.
B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise.
C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.
A nurse is assessing a patient who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what?
- A. Urinary tract infection
- B. Chronic pain
- C. Permanent vascular damage
- D. Future erectile dysfunction
Correct Answer: C
Rationale: The correct answer is C: Permanent vascular damage. Priapism is a prolonged erection that can lead to ischemia and damage to the penile tissue due to impaired blood flow, potentially resulting in permanent vascular damage. Urinary tract infection (A) is unrelated to priapism. Chronic pain (B) may occur but is not the primary concern. Future erectile dysfunction (D) can result from priapism but is not as immediate or severe as permanent vascular damage. Therefore, C is the most critical consequence to address in priapism.
A nurse has assessed that a patient is not yet willing to view her mastectomy site. How should the nurse best assist the patient is developing a positive body image?
- A. Ask the woman to describe the current appearance of her breast.
- B. Help the patient to understand that many women have gone through the same unpleasant experience.
- C. Explain to the patient that her body image does not have to depend on her physical appearance.
- D. Provide the patient with encouragement in an empathic and thoughtful manner.
Correct Answer: D
Rationale: Step 1: Providing encouragement is essential to building trust and rapport with the patient, which is crucial in supporting her emotional needs.
Step 2: Empathy helps the patient feel understood and supported, fostering a positive therapeutic relationship.
Step 3: Thoughtful encouragement acknowledges the patient's feelings and validates her experiences, empowering her to gradually accept her body changes.
Step 4: By offering empathic and thoughtful encouragement, the nurse helps the patient develop a positive body image at her own pace.
Choice A focuses on physical appearance, Choice B generalizes experiences, and Choice C overlooks the patient's emotional journey.
The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
- A. Measuring capillary blood glucose level
- B. Measuring nasoenteric tube for insertion
- C. Measuring pH in gastrointestinal aspirate
- D. Measuring the patient’s risk for aspiration
Correct Answer: A
Rationale: The correct answer is A because measuring capillary blood glucose level is a task that can be safely delegated to nursing assistive personnel. This task is within their scope of practice and does not require specialized nursing knowledge. Nursing assistive personnel can perform this task accurately with proper training and supervision.
Incorrect choices:
B: Measuring nasoenteric tube for insertion requires specialized training and assessment skills that nursing assistive personnel may not possess.
C: Measuring pH in gastrointestinal aspirate involves interpretation and clinical judgment that should be done by a licensed nurse.
D: Measuring the patient's risk for aspiration involves critical thinking and assessment skills that are beyond the scope of nursing assistive personnel.
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.