Nokea
A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?
- A. Assessment of peripheral nervous function
- B. Assessment of cranial nerve function
- C. Assessment of nutritional status
- D. Assessment of respiratory status
Correct Answer: C
Rationale: The correct answer is C: Assessment of nutritional status. Cachexia is a complex metabolic syndrome characterized by weight loss, muscle wasting, and weakness commonly seen in cancer patients. Assessing the patient's nutritional status is crucial to address the underlying causes of cachexia and to develop an appropriate management plan. This assessment includes evaluating dietary intake, weight changes, body composition, and nutritional deficiencies.
Choice A: Assessment of peripheral nervous function is not the priority in this case as cachexia is primarily related to metabolic and nutritional issues rather than peripheral nervous system dysfunction.
Choice B: Assessment of cranial nerve function is also not the priority since cachexia is not directly associated with cranial nerve dysfunction.
Choice D: Assessment of respiratory status may be important in general patient care, but in this case, addressing the underlying nutritional issues that are contributing to cachexia should be the priority.
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A nurse is caring for a patient with a continenturinary reservoir. Which action will the nurse take?
- A. Teach the patient how to self-cath the pouch.
- B. Teach the patient how to perform Kegel exercises.
- C. Teach the patient how to change the collection pouch.
- D. Teach the patient how to void using the Valsalva technique. In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using a Valsalva technique. In a ureterostomy or ileal conduit the patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. Kegel exercises are ineffective for a patient with a continent urinary reservoir.
Correct Answer: A
Rationale: The correct answer is A: Teach the patient how to self-cath the pouch. In a continent urinary reservoir, patients need to catheterize the pouch several times a day. This is essential for emptying the urine from the pouch as the ileocecal valve creates a one-way valve. Teaching the patient how to self-catheterize ensures proper and timely drainage, preventing complications like urinary retention. Self-catheterization also empowers the patient to take an active role in managing their continence.
Summary of other choices:
B: Kegel exercises are ineffective for a patient with a continent urinary reservoir as they do not address the need for catheterization.
C: Changing the collection pouch is not the primary action needed for a continent urinary reservoir. Catheterization is essential for drainage.
D: The Valsalva technique is not appropriate for voiding in a continent urinary reservoir. Catheterization is the recommended method for emptying the pouch.
A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
- A. “I know I will need to have an abortion as soon as possible.”
- B. “Even though my test is positive, my baby might not be affected.”
- C. “My baby is certain to have AIDS and die within the first year of life.”
- D. “This pregnancy will probably decrease the chance that I will develop AIDS.”
Correct Answer: B
Rationale: The correct answer is B because it shows an understanding that being HIV-positive does not guarantee transmission to the baby. The statement acknowledges the possibility of the baby not being affected, which demonstrates awareness of the varying outcomes. Choice A is incorrect as it assumes abortion is the only option. Choice C is incorrect as it makes an extreme and inaccurate claim. Choice D is incorrect as pregnancy does not decrease the chance of developing AIDS.
The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
- A. Observe the color of gastric contents.
- B. Verify tube placement before feeding.
- C. Add blue food coloring to the enteral formula.
- D. Run the formula over 12 hours to decrease overload.
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be?
- A. Ossiculitis
- B. Mnires disease
- C. Ototoxicity
- D. Labyrinthitis
Correct Answer: D
Rationale: The correct answer is D: Labyrinthitis. This condition presents with sudden onset vertigo, nausea, vomiting, tinnitus, and hearing loss, which are all symptoms described by the patient. Labyrinthitis is commonly caused by a viral infection affecting the inner ear, leading to inflammation of the labyrinth. This inflammation disrupts the balance and hearing functions of the inner ear, resulting in the symptoms mentioned.
A: Ossiculitis involves inflammation of the middle ear bones, typically causing conductive hearing loss, not the sudden onset of vertigo and other symptoms described.
B: Mnire's disease is characterized by recurrent episodes of vertigo, tinnitus, and hearing loss, but it typically does not present with sudden onset incapacitating vertigo.
C: Ototoxicity is caused by exposure to certain medications or chemicals that damage the inner ear structures, leading to hearing loss. While hearing loss is a symptom, the sudden onset of vertigo is not typically associated with ototoxicity.
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
- A. The malleus can be visualized during otoscopic examination.
- B. The tympanic membrane is pearly gray.
- C. Tenderness is reported by the patient when the mastoid area is palpated.
- D. Clear, watery fluid is draining from the patients ear.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis.
2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents.
3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications.
Summary:
A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario.
B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident.
C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.