Nokea
After a thoracentesis on a client with a pleural effusion, which nursing intervention is most important post-procedure?
- A. Monitor for signs of infection.
- B. Assess for signs of bleeding or hematoma.
- C. Monitor vital signs and respiratory status.
- D. Instruct the client to rest and limit physical activity.
Correct Answer: B
Rationale: The correct answer is to assess for signs of bleeding or hematoma. After a thoracentesis, it is crucial to monitor for any bleeding or hematoma formation at the puncture site, as this can lead to complications. Monitoring for signs of infection (Choice A) is essential but is usually a delayed concern compared to the immediate risk of bleeding post-procedure. While monitoring vital signs and respiratory status (Choice C) is important, assessing for bleeding takes precedence to address any immediate complications. Instructing the client to rest and limit physical activity (Choice D) is relevant for general post-procedure care but is not the most critical intervention in this scenario.
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What nursing diagnosis is suggested by the patient's statement regarding taking extra griseofulvin when she thinks her infection is getting worse?
- A. Deficient knowledge related to correct use of griseofulvin
- B. Effective therapeutic regimen management related to symptom identification
- C. Disturbed thought processes related to appropriate use of griseofulvin
- D. Ineffective coping related to self-medication
Correct Answer: C
Rationale: The correct answer is C: 'Disturbed thought processes related to appropriate use of griseofulvin.' The patient's statement shows a misunderstanding of the correct use of griseofulvin by taking extra medication when she believes her infection is worsening. This behavior indicates a disturbance in her thought process regarding the appropriate use of the medication. Choice A is incorrect because the issue is not lack of knowledge but rather a misunderstanding leading to inappropriate actions. Choice B is incorrect as the patient's actions do not demonstrate effective management of her therapeutic regimen. Choice D is incorrect as the patient is not engaged in self-medication but rather misinterpreting signals and self-adjusting the prescribed medication.
When educating a patient starting on oral contraceptives, what should the nurse include in the teaching plan regarding potential side effects?
- A. Weight gain, mood changes, and nausea
- B. Increased appetite, insomnia, and fatigue
- C. Breast tenderness, headaches, and dizziness
- D. Fatigue, hair loss, and joint pain
Correct Answer: A
Rationale: The correct answer is A: Weight gain, mood changes, and nausea are common side effects of oral contraceptives. Weight gain may occur due to fluid retention or changes in metabolism. Mood changes can be caused by hormonal fluctuations. Nausea is a common side effect that usually improves after a few months of use. Choices B, C, and D are incorrect because they do not reflect common side effects associated with oral contraceptives. Increased appetite, insomnia, breast tenderness, headaches, dizziness, fatigue, hair loss, and joint pain are not typically reported side effects of oral contraceptives.
A patient is being educated about sildenafil (Viagra). Which of the following statements by the patient indicates that further teaching is necessary?
- A. I can take this medication with nitroglycerin.
- B. This medication can cause an erection lasting more than 4 hours.
- C. I should not take this medication if I am taking medications containing nitrates.
- D. This medication is safe to take with any over-the-counter medication.
Correct Answer: A
Rationale: The correct answer is A because sildenafil should not be taken with medications containing nitrates, such as nitroglycerin, due to the risk of severe hypotension. Choice B is incorrect because priapism (prolonged erection) is a serious side effect but does not require immediate intervention like severe hypotension. Choice C is incorrect as it correctly identifies a contraindication for sildenafil use. Choice D is incorrect because not all over-the-counter medications are safe to take with sildenafil, and interactions can occur.
A patient arrives at her follow-up appointment 1 month post-hysterectomy and complains to the nurse that her scars do not seem to be healing properly. Upon inspection, the nurse notices that the scars are raised but still within the boundaries of the original incisions. The nurse tells the patient this kind of dysfunctional wound healing is called:
- A. Hypertrophic scarring
- B. Dehiscence
- C. Contracture
- D. A keloid
Correct Answer: A
Rationale: Hypertrophic scarring occurs when a scar is raised but remains within the boundaries of the original wound, unlike keloids, which extend beyond the wound edges. Dehiscence refers to the separation of wound edges, while contracture involves the tightening or constriction of a scar, leading to limited mobility.
What is the primary therapeutic action of tamsulosin (Flomax) in a male patient with benign prostatic hyperplasia (BPH)?
- A. Relaxation of the muscles in the prostate and bladder neck, leading to improved urinary flow.
- B. Reduction in prostate size and improvement in urinary symptoms.
- C. Increase in urine flow and relief of urinary obstruction.
- D. Improvement in erectile function.
Correct Answer: A
Rationale: The correct answer is A: Relaxation of the muscles in the prostate and bladder neck, leading to improved urinary flow. Tamsulosin, a medication commonly prescribed for BPH, works by selectively blocking alpha-1 adrenergic receptors in the prostate, causing relaxation of smooth muscles in the prostate and bladder neck. This relaxation reduces the constriction in these areas, improving urinary flow and reducing symptoms such as hesitancy, urgency, frequency, and weak stream. Choice B is incorrect because tamsulosin does not directly reduce the size of the prostate. Choice C is incorrect as tamsulosin primarily acts by relaxing muscles rather than directly increasing urine flow. Choice D is incorrect as tamsulosin is not indicated for improving erectile function.