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A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
- A. Preparing to administer a barium enema
- B. Withholding narcotic pain medication
- C. Administering laxatives to the patient
- D. Raising the head of the bed
Correct Answer: D
Rationale: Rationale: Option D is correct because raising the head of the bed promotes a more natural position for defecation, allowing gravity to assist. This position helps align the rectum and anal canal, making it easier for the patient to have a bowel movement. Administering laxatives (Option C) may help, but adjusting the bed position is a non-invasive and more immediate intervention. Withholding pain medication (Option B) could lead to unnecessary discomfort for the patient. Administering a barium enema (Option A) is not indicated for addressing difficulty with defecation.
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When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurses initial intervention for this patient?
- A. Generously flush the affected eye with a dilute antibiotic solution.
- B. Generously flush the affected eye with normal saline or water.
- C. Apply a patch to the affected eye.
- D. Apply direct pressure to the affected eye.
Correct Answer: B
Rationale: The correct initial intervention for a chemical burn to the eye is to generously flush the affected eye with normal saline or water. Flushing helps to remove the chemical from the eye, preventing further damage. Antibiotic solution (choice A) is not the first intervention as the priority is to remove the chemical. Applying a patch (choice C) can trap the chemical against the eye, worsening the injury. Applying direct pressure (choice D) is not appropriate and can cause additional harm. Flushing with normal saline or water is the most effective and safest initial intervention to minimize damage from a chemical burn to the eye.
A nurse is planning the postoperative care of a patient who is scheduled for radical prostatectomy. What intraoperative position will place the patient at particular risk for the development of deep vein thrombosis postoperatively?
- A. Fowlers position
- B. Prone position
- C. Supine position
- D. Lithotomy position
Correct Answer: D
Rationale: The correct answer is D: Lithotomy position. In lithotomy position, the patient's legs are elevated and positioned higher than the heart, which can lead to venous stasis and increase the risk of deep vein thrombosis (DVT). This position compresses the femoral veins, hindering blood flow and predisposing the patient to DVT formation.
Summary:
A: Fowlers position - Not typically associated with increased DVT risk.
B: Prone position - Not typically associated with increased DVT risk.
C: Supine position - Generally considered a safe position regarding DVT risk.
A nurse is caring for an 8-year-old patient whois embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?
- A. “Set your alarm clock to wake you every 2 hours, so you can get up to void.”
- B. “Line your bedding with plastic sheets to protect your mattress.”
- C. “Drink your nightly glass of milk earlier in the evening.”
- D. “Empty your bladder completely before going to bed.”
Correct Answer: C
Rationale: The correct answer is C: “Drink your nightly glass of milk earlier in the evening.” By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake.
Explanation for why the other choices are incorrect:
A: “Set your alarm clock to wake you every 2 hours, so you can get up to void.” This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting.
B: “Line your bedding with plastic sheets to protect your mattress.” This intervention focuses on managing the consequences of bedwetting rather than preventing it.
D: “Empty your bladder completely before going to bed.” While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.
A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis?
- A. Malleus
- B. Stapes
- C. Incus
- D. Tympanic membrane
Correct Answer: B
Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.