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A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
- A. Utilize a pressure-reducing mattress.
- B. Limit the patients physical activity.
- C. Apply antibiotic ointment to dependent skin surfaces.
- D. Avoid contact with synthetic fabrics.
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.
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A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply.
- A. Diabetic retinopathy
- B. Trauma
- C. Macular degeneration
- D. Cytomegalovirus E) Glaucoma
Correct Answer: A
Rationale: The correct answer is A: Diabetic retinopathy. This is because diabetic retinopathy is a leading cause of blindness in adults over 40, resulting from diabetes affecting blood vessels in the retina. Trauma (B) is a common cause of visual impairment but not as prevalent as diabetic retinopathy in this age group. Macular degeneration (C) primarily affects older individuals, typically over 50, rather than those over 40. Cytomegalovirus (D) is a cause of blindness in immunocompromised individuals, not specific to the age group mentioned. Glaucoma (E) is a leading cause of blindness worldwide but is more common in older adults and not specifically over 40.
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
- A. Application of topical antibiotic ointment
- B. Maintenance of a supine position for the first 48 hours postoperative
- C. Fluid restriction to prevent orbital edema
- D. Administration of loop diuretics to prevent orbital edema E) Use of an ocular pressure dressing Chapter 64: Ear/Hearing: Hearing tests, Hearing loss, Otitis externa, Otitis media, Trauma, Meniere’s disease, Mastoidectomy – perioperative care, Impacted cerumen & Cochlear implant
Correct Answer: A
Rationale: The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care.
B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site.
C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider.
D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation.
E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more
The nurse is planning care for a group of patients.Which task will the nurse assign to the nursing assistive personnel (NAP)?
- A. Performing the first postoperative pouch change
- B. Maintaining a nasogastric tube
- C. Administering an enema
- D. Digitally removing stool
Correct Answer: C
Rationale: Correct Answer: C - Administering an enema
Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making.
Summary of other choices:
A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse.
B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse.
D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons, but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect is theproblem with the 14-year-old?
- A. Vulvitis
- B. Vulvodynia
- C. Vaginitis
- D. Bartholins cyst
Correct Answer: B
Rationale: The correct answer is B: Vulvodynia. Vulvodynia is characterized by chronic vulvar pain or discomfort, including stabbing pain and burning, without an identifiable cause. In this case, the young girl is experiencing these symptoms despite not being sexually active, ruling out other conditions like vulvitis (inflammation of the vulva), vaginitis (inflammation of the vagina), and Bartholin's cyst (fluid-filled swelling near the vaginal opening). The absence of sexual activity suggests that the pain is not related to an infection or trauma, further supporting the diagnosis of vulvodynia.
A nurse has asked the nurse educator if there is any way to predict the severity of a patients anaphylactic reaction. What would be the nurses best response?
- A. The faster the onset of symptoms, the more severe the reaction.
- B. The reaction will be about one-third more severe than the patients last reaction to the same antigen.
- C. There is no way to gauge the severity of a patients anaphylaxis, even if it has occurred repeatedly in the past.
- D. The reaction will generally be slightly less severe than the last reaction to the same antigen.
Correct Answer: C
Rationale: The correct answer is C because the severity of an anaphylactic reaction can vary greatly from one episode to another in the same patient. Anaphylactic reactions are unpredictable and can be influenced by various factors such as the amount of allergen exposure, individual immune response, underlying health conditions, and concurrent medications. Therefore, it is not possible to reliably gauge the severity of a patient's anaphylactic reaction even if it has occurred repeatedly in the past.
Choice A is incorrect because the onset of symptoms alone is not a reliable predictor of the severity of the reaction. Choice B is incorrect as well because there is no set formula to predict that the reaction will be one-third more severe than the patient's last reaction. Choice D is incorrect because stating that the reaction will generally be slightly less severe than the last reaction is also not accurate or supported by evidence.