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A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
- A. Risk for Disuse Syndrome Related to Kaposis Sarcoma B)Impaired Skin Integrity Related to Kaposis Sarcoma C)Diarrhea Related to Kaposis Sarcoma
- B. Impaired Swallowing Related to Kaposis Sarcoma
Correct Answer: B
Rationale: The correct answer is B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing.
Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma. Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma. Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.
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The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.)
- A. Breech presentation
- B. Ectopic pregnancy
- C. Birth defects
- D. Venous thromboembolism
Correct Answer: A
Rationale: The correct answer is A: Breech presentation. Obesity can lead to a larger fetus, increasing the risk of breech presentation. The rationale is that excess fat can hinder the baby's ability to turn head down. Other choices are incorrect because: B: Ectopic pregnancy is not related to obesity, C: Birth defects can be influenced by maternal health but are not directly linked to obesity, and D: Venous thromboembolism is more associated with immobility and hypercoagulable states rather than obesity.
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?
- A. Assessing for mouth droop and decreased lateral eye gaze
- B. Assessing for increased middle ear pressure and perforated ear drum
- C. Assessing for gradual onset of conductive hearing loss and nystagmus
- D. Assessing for scar tissue and cerumen obstructing the auditory canal
Correct Answer: A
Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications.
Choices B, C, and D are incorrect:
B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient.
C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively.
D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.
The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
- A. Use of a bedpan
- B. Use of a raised toilet seat
- C. Sitting quietly on the toilet every 2 hours
- D. Following the outlined bowel program
Correct Answer: B
Rationale: Correct Answer: B - Use of a raised toilet seat
Rationale: A raised toilet seat helps the patient with Parkinson's disease by providing additional height, making it easier for them to transition from sitting to standing. This aids in improving mobility and reducing the risk of falls. Furthermore, the raised seat can also promote proper positioning for bowel elimination, making the process more comfortable and effective.
Incorrect Choices:
A: Using a bedpan does not address the issue of transitioning from sitting to standing, nor does it aid in improving bowel elimination for the patient.
C: Sitting quietly on the toilet every 2 hours may not directly address the physical challenges the patient is facing in transitioning from sitting to standing.
D: Following the outlined bowel program is important, but it does not specifically address the physical support needed to transition from sitting to standing for a patient with Parkinson's disease.
To decrease glandular cellular activity and prostate size, an 83-year-old patient has been prescribed finasteride (Proscar). When performing patient education with this patient, the nurse should be sure to tell the patient what?
- A. Report the planned use of dietary supplements to the physician.
- B. Decrease the intake of fluids to prevent urinary retention.
- C. Abstain from sexual activity for 2 weeks following the initiation of treatment.
- D. Anticipate a temporary worsening of urinary retention before symptoms subside.
Correct Answer: A
Rationale: Step 1: Finasteride is a medication that works by decreasing glandular cellular activity and reducing prostate size.
Step 2: Dietary supplements can interact with finasteride, potentially affecting its effectiveness or causing adverse effects.
Step 3: Reporting the planned use of dietary supplements to the physician ensures proper monitoring and adjustment of the treatment plan.
Step 4: This communication promotes patient safety and optimal therapeutic outcomes.
Therefore, choice A is correct as it emphasizes the importance of informing the physician about dietary supplement use to ensure the efficacy and safety of finasteride. Choices B, C, and D are incorrect as they do not directly relate to the mechanism of action or specific considerations of finasteride therapy.
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
- A. Have the patient void and have bowel movements using a commode rather than toilet.
- B. Count and inspect each perineal pad that the patient uses.
- C. Swab the patients perineum for the presence of blood at least once per shift.
- D. Leave the patients perineum open to air to facilitate inspection.
Correct Answer: B
Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage.
A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring.
C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads.
D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.