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A patient with advanced dementia is no longer able to communicate verbally and displays signs of distress. What should the palliative nurse consider when assessing and managing the patient's distress?
- A. Focus solely on physical comfort measures to alleviate distress.
- B. Assume the patient's distress is solely related to physical discomfort.
- C. Explore non-verbal cues and behaviors to identify the underlying causes of distress.
- D. Administer sedative medications to manage the patient's agitation.
Correct Answer: C
Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.
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A patient presents with fatigue, pallor, and dyspnea on exertion. Laboratory tests reveal a low hemoglobin level, decreased mean corpuscular volume (MCV), and decreased mean corpuscular hemoglobin concentration (MCHC). Which of the following conditions is most likely to cause these findings?
- A. Iron deficiency anemia
- B. Vitamin B12 deficiency anemia
- C. Thalassemia
- D. Sickle cell anemia
Correct Answer: A
Rationale: The patient's presentation with fatigue, pallor, dyspnea on exertion, low hemoglobin level, decreased MCV, and decreased MCHC are all consistent with iron deficiency anemia. Iron deficiency anemia is the most common type of anemia and occurs when there is insufficient iron available for hemoglobin production. The low hemoglobin level results in symptoms such as fatigue and pallor, while the decreased MCV and MCHC indicate microcytic and hypochromic red blood cells, respectively, which are characteristic of iron deficiency anemia. Vitamin B12 deficiency anemia and thalassemia typically present with a different pattern of laboratory findings and clinical manifestations. Sickle cell anemia is characterized by sickle-shaped red blood cells due to a genetic mutation, and the laboratory findings in sickle cell anemia are different from those seen in the patient described in this scenario.
A woman in active labor experiences irregular and ineffective uterine contractions, resulting in prolonged cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?
- A. Encourage the mother to ambulate and change positions frequently.
- B. Administer intravenous opioids to enhance pain relief and relaxation.
- C. Initiate continuous electronic fetal monitoring to assess fetal well-being.
- D. Prepare for immediate cesarean section due to labor dystocia.
Correct Answer: A
Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.
A patient presents with sudden onset of severe, unilateral ear pain, diminished hearing, and purulent otorrhea. Otoscopic examination reveals a bulging, erythematous tympanic membrane with obscured landmarks. Which of the following conditions is most likely responsible for this presentation?
- A. Otitis externa
- B. Acute otitis media
- C. Mastoiditis
- D. Chronic suppurative otitis media
Correct Answer: B
Rationale: Acute otitis media is the most likely condition responsible for this presentation. The sudden onset of severe, unilateral ear pain, diminished hearing, and purulent otorrhea are classic symptoms of acute otitis media. Otoscopic examination revealing a bulging, erythematous tympanic membrane with obscured landmarks further supports the diagnosis. The bulging of the tympanic membrane is due to the accumulation of fluid and pus behind it, causing the characteristic appearance. Treatment typically involves antibiotics to help clear the infection and relieve symptoms. If left untreated, acute otitis media can lead to complications such as perforation of the eardrum or mastoiditis.
One GOOD nursing intervention of the nurse for Almira would be to do which of the following?
- A. Advise her to eat her meals.
- B. Put her on absolute bed rest.
- C. Take the vital signs q 4 hours.
- D. Advise her to take care of Jay.
Correct Answer: A
Rationale: The correct nursing intervention for Almira would be to advise her to eat her meals. This is important in promoting her health and well-being, especially if she has been neglecting her own nutrition due to stress or caring for her son, Jay. Providing proper nutrition is a basic aspect of nursing care that supports the overall health and recovery of the patient. By encouraging Almira to prioritize her own nutrition, the nurse can help ensure that she has the physical strength and energy needed to take care of herself and her son effectively.
A patient expresses confusion about their medication regimen. What is the nurse's best approach to address this issue?
- A. Provide the patient with written instructions only.
- B. Explain the medication regimen using complex medical terminology.
- C. Use a teach-back method to assess understanding and clarify any misconceptions.
- D. Dismiss the patient's concerns and reassure them that the medication is safe.
Correct Answer: C
Rationale: The nurse's best approach to address the patient's confusion about their medication regimen is to use a teach-back method to assess understanding and clarify any misconceptions. This method involves the nurse asking the patient to explain in their own words how they will take their medications, what each medication is for, and any potential side effects they should watch for. By using the teach-back method, the nurse can confirm the patient's comprehension and correct any misunderstandings in a supportive and non-judgmental manner. This approach promotes patient education, empowerment, and adherence to the medication regimen. Providing written instructions alone (Choice A) may not be sufficient if the patient has difficulty reading or understanding written information. Explaining the medication regimen using complex medical terminology (Choice B) can further confuse the patient, making it harder for them to grasp the information. Dismissing the patient's concerns and reassuring them that the medication is safe (Choice D) does not address the root of the issue and