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A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
- A. Request that the family leave, so the patient can rest.
- B. Ask the patient to return to the room, so the nurse can inspect the abdomen.
- C. Ask the patient when the last bowel movement was and to lie down on the sofa. Tell the patient that the dinner tray will be ready in 15 minutes and that may help
- D. the stomach feel better.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen.
Rationale:
1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues.
2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately.
3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support.
Summary:
A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system.
C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort.
D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.
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Three days after admission Ms. CC continued to have frequent stools. Her oral intake of both fluids and solids are poor. Her physician ordered parenteral hyperalimentation. Hyperalimentation solutions are:
- A. Hypotonic solutions used primarily to increase osmotic pressure of blood plasma
- B. Hypertonic solutions used primarily for hydration when hemoconcentration is present
- C. Alkalizing solutions used to treat metabolic acidosis thus reducing cellular sweating
- D. Hyperosmolar solutions used primarily to reverse negative nitrogen balance
Correct Answer: D
Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance.
Rationale:
1. Hyperalimentation solutions are designed to provide essential nutrients intravenously.
2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition.
3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake.
4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance.
Summary:
A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it.
B: Hypertonic solutions are not primarily used for hydration in this context.
C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
- A. Sleep with the head of the bed slightly
- B. Use a soft toothbrush and electric razor
- C. Drink citrus juices frequently for nourishment
- D. Increase his activity level and ambulates frequently
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because:
A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression.
C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding.
D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation.
Incorrect Choices:
A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns.
C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication.
D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: Step 1: Providing referral to support groups and resources for information is essential for HIV positive clients as it offers emotional support, education, and access to resources for managing the condition.
Step 2: Support groups provide a safe space for clients to share experiences, seek advice, and reduce feelings of isolation.
Step 3: Resources for information help clients stay informed about their condition, treatment options, and lifestyle modifications.
Step 4: Referral to support groups and resources promotes holistic care and enhances the client's overall well-being.
Summary: Choices A, B, and C are incorrect as they do not address the specific needs of HIV positive clients and may even pose risks to their health. Option D is the most appropriate intervention as it focuses on comprehensive support and empowerment for clients.
Which of the following is information the nurse would be correct in giving the patient about smoking and its effect on BP?
- A. It is associated with stages 1 and 2 hypertension.
- B. It does not affect BP regulation.
- C. It vasodilates the peripheral blood vessels.
- D. It causes sustained BP elevation.
Correct Answer: A
Rationale: The correct answer is A: It is associated with stages 1 and 2 hypertension. Smoking is a major risk factor for developing hypertension, especially stages 1 and 2. Nicotine in cigarettes can lead to vasoconstriction, increased heart rate, and overall elevated blood pressure. This information is crucial for patients to understand the direct impact of smoking on their blood pressure levels.
Choice B is incorrect because smoking does indeed affect BP regulation by causing vasoconstriction and elevated heart rate. Choice C is incorrect as smoking actually causes vasoconstriction rather than vasodilation. Choice D is incorrect because smoking does lead to sustained elevation of blood pressure, especially in the long term.