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A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurses best response?
- A. I can only imagine how you feel. Would you like to talk about it?
- B. Lets find a quiet spot and Ill teach you a few coping strategies.
- C. Thats the same way that most patients who have a chronic illness feel.
- D. Do you think that maybe you could be managing things more efficiently?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship.
Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.
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A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
- A. Blowing up balloons
- B. Deliberately frowning
- C. Smiling repeatedly
- D. Whistling
Correct Answer: A
Rationale: The correct answer is A: Blowing up balloons. Blowing up balloons involves the activation of the facial muscles, which helps prevent muscle atrophy in patients with Bell's palsy. This exercise promotes muscle strength and prevents weakness. Deliberately frowning (B), smiling repeatedly (C), and whistling (D) do not specifically target the facial muscles involved in Bell's palsy and may not be as effective in preventing muscle atrophy.
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
- A. Reassure the patient that she will still be able to have children.
- B. Reassure the patient that she does not have to have sex to be feminine.
- C. Reassure the patient that you know how she is feeling and that you feel her anxiety and pain.
- D. Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm.
Correct Answer: B
Rationale: The correct answer is B: Reassure the patient that she does not have to have sex to be feminine.
Rationale:
1. Acknowledges patient's feelings: By reassuring the patient that she does not have to have sex to be feminine, the nurse validates the patient's emotions and concerns.
2. Addresses societal norms: This intervention challenges societal stereotypes that equate femininity solely with reproductive capabilities.
3. Promotes self-acceptance: Encouraging the patient to embrace her femininity beyond physical aspects fosters self-acceptance and self-worth.
4. Supports holistic care: Recognizing the multifaceted nature of femininity shows a holistic approach to addressing the patient's body image issues.
Summary:
A, C, and D are incorrect as they do not directly address the patient's specific concerns about her body image and femininity. Choice B is the most appropriate intervention as it validates the patient's feelings and challenges societal norms, promoting self-acceptance and holistic care
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?
- A. Ask the patient when she last had anything to eat or drink.
- B. Take a culture of the lesions to verify the involved organism.
- C. Ask the patient if she has had unprotected sex since her outbreak.
- D. Use electronic fetal surveillance to determine a baseline fetal heart rate.
Correct Answer: D
Rationale: The correct answer is D: Use electronic fetal surveillance to determine a baseline fetal heart rate. This is important in assessing the well-being of the fetus during labor, especially in the presence of genital herpes lesions. Monitoring the fetal heart rate helps in detecting any signs of distress or compromise due to maternal infection.
A: Asking about the patient's last intake is important but not the immediate priority when managing a patient with active genital herpes lesions in labor.
B: Taking a culture of the lesions might be helpful but not the immediate action needed in this situation.
C: Asking about unprotected sex is relevant but not as critical as monitoring the fetal well-being during labor in this scenario.
Overall, the most critical action is to monitor the fetal heart rate for any signs of distress related to the maternal herpes infection.
A patient develops a foodborne disease fromEscherichiacoli. When taking a health history, which food item will the nursemostlikely find the patient ingested?
- A. Improperly home-canned food
- B. Undercooked ground beef
- C. Soft cheese
- D. Custard
Correct Answer: B
Rationale: The correct answer is B: Undercooked ground beef. Escherichia coli is commonly found in undercooked ground beef, especially if it is contaminated during processing. Ground beef must be cooked to a safe internal temperature to kill any harmful bacteria. Improperly home-canned food (choice A) can also cause foodborne illnesses, but E. coli is more commonly associated with undercooked ground beef. Soft cheese (choice C) is often linked to Listeria contamination, not E. coli. Custard (choice D) is a less likely source of E. coli compared to undercooked ground beef.
In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?
- A. Weight increases.
- B. Weight decreases.
- C. Weight does not change.
- D. Weight fluctuates daily.
Correct Answer: C
Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance.
A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain.
B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss.
D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.