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A patient with a genital herpes exacerbation has a nursing diagnosis of acute pain related to the genital lesions. What nursing intervention best addresses this diagnosis?
- A. Cover the lesions with a topical antibiotic.
- B. Keep the lesions clean and dry.
- C. Apply a topical NSAID to the lesions.
- D. Remain on bed rest until the lesions resolve.
Correct Answer: B
Rationale: The correct answer is B: Keep the lesions clean and dry. This intervention helps prevent infection and promotes healing. Cleaning the lesions reduces the risk of secondary infections and discomfort. Keeping the area dry can also help alleviate pain and discomfort associated with moisture. Covering with a topical antibiotic (A) may not address pain directly and could potentially irritate the lesions. Applying a topical NSAID (C) may provide some pain relief but does not address the primary need to keep the lesions clean and dry. Remaining on bed rest (D) is not necessary for managing acute pain related to genital lesions.
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A nurse is using the RESPECT mnemonic to establishrapport, the “R” in RESPECT. Which actions should the nurse take? (Select all that apply.)
- A. Connect on a social level.
- B. Help the patient overcome barriers.
- C. Consciously attempt to suspend judgment.
- D. Stress that they will be working together to address problems.
Correct Answer: A
Rationale: The correct answer is A: Connect on a social level. In the RESPECT mnemonic, "R" stands for "Rapport," which is crucial in building a therapeutic relationship with the patient. Connecting on a social level helps establish trust, empathy, and understanding between the nurse and the patient. This connection can lead to better communication, collaboration, and ultimately improved patient outcomes.
Summary:
- Choice B: Helping the patient overcome barriers is important but not specifically related to establishing rapport in the RESPECT mnemonic.
- Choice C: Suspending judgment is important for effective communication but does not directly address building rapport.
- Choice D: Stressing collaboration is valuable but does not specifically focus on connecting on a social level to build rapport.
A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patients skin appears yellow. Which blood tests should be done to further explore this clinical sign?
- A. Liver function tests (LFTs)
- B. Complete blood count (CBC)
- C. Platelet count
- D. Blood urea nitrogen and creatinine
Correct Answer: A
Rationale: The correct answer is A: Liver function tests (LFTs). Yellow skin can indicate jaundice, a sign of liver dysfunction, often seen in patients with liver issues or chemotherapy-related liver toxicity. LFTs including bilirubin, ALT, AST, and ALP can help assess liver function.
B: Complete blood count (CBC) and C: Platelet count are not directly related to yellow skin and would not provide information on liver function.
D: Blood urea nitrogen and creatinine are tests for kidney function, not liver function. While kidney dysfunction can sometimes cause yellow skin, LFTs are more specific for assessing liver function in this context.
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?
- A. Pruritis (itching)
- B. Nausea and vomiting
- C. Altered glucose metabolism
- D. Confusion
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapy commonly causes gastrointestinal side effects, such as nausea and vomiting, due to its impact on rapidly dividing cells in the digestive tract. This adverse effect can significantly impact a patient's quality of life and adherence to treatment. Pruritis (A), itching, is less common and usually not a primary side effect of chemotherapy. Altered glucose metabolism (C) is a potential effect of some chemotherapeutic agents but is not the most common adverse effect. Confusion (D) is not typically associated with chemotherapy and is more commonly seen with other medications or medical conditions.
A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient?
- A. Promoting adequate perfusion in affected regions
- B. Promoting safe use of topical antihistamines
- C. Identifying the offending agent, if possible
- D. Teaching the patient to safely use an EpiPen
Correct Answer: C
Rationale: The correct answer is C: Identifying the offending agent, if possible. This is prioritized in contact dermatitis to prevent further exposure and recurrence. By identifying the specific irritant or allergen, the nurse can guide the patient in avoiding it, leading to effective management. Choices A, B, and D are incorrect because while promoting adequate perfusion, safe use of topical antihistamines, and teaching the use of an EpiPen may be relevant in certain situations, they do not directly address the root cause of contact dermatitis, which is exposure to the offending agent.
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.