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After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patients home care?
- A. Preparation of nutritious meals and avoidance of contraindicated foods
- B. Ensuring the patient receives adequate rest each day
- C. Helping the patient adapt to temporary hearing loss
- D. Assisting the patient with ambulation as needed to avoid falling
Correct Answer: A
Rationale: The correct answer is A: Preparation of nutritious meals and avoidance of contraindicated foods. After mastoid surgery, proper nutrition is crucial for healing and recovery. Nutritious meals support the immune system and aid in tissue repair. Avoiding contraindicated foods, such as those that may cause inflammation or interfere with medications, is essential for the patient's well-being. Choices B, C, and D are not the primary focus of home care after mastoid surgery. While rest, adaptation to hearing loss, and assistance with ambulation are important, they are secondary to ensuring proper nutrition for optimal recovery in this case.
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The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying?
- A. Depression
- B. Denial
- C. Anger
- D. Resignation .
Correct Answer: A
Rationale: The correct answer is A: Depression. In the context of the stages of death and dying proposed by Elisabeth Kübler-Ross, a patient exhibiting signs of loss, grief, and intense sadness is likely in the depression stage. This stage involves feelings of hopelessness, despair, and sorrow as the patient comes to terms with the reality of their situation. Denial (choice B) is characterized by a refusal to accept the diagnosis, anger (choice C) involves feelings of resentment and frustration, and resignation (choice D) signifies a sense of acceptance and peace. In this scenario, the patient's emotional state aligns most closely with depression, indicating a deep sense of sadness and mourning.
The nurse is caring for a patient withClostridiumdifficile. Which nursing actions will have thegreatest impact in preventing the spread of the bacteria?
- A. Appropriate disposal of contaminated items in biohazard bags
- B. Monthly in-services about contact precautions
- C. Mandatory cultures on all patients
- D. Proper hand hygiene techniques
Correct Answer: D
Rationale: Correct Answer: D - Proper hand hygiene techniques
Rationale:
1. Clostridium difficile is mainly spread through contact with contaminated surfaces.
2. Proper hand hygiene is the most effective way to prevent the spread of bacteria.
3. Hand hygiene removes bacteria from hands, reducing the risk of transmission.
4. Appropriate disposal (A) is important but doesn't directly prevent spread. Monthly in-services (B) and mandatory cultures (C) are not as effective as hand hygiene in preventing transmission.
A nurse administers an antimuscarinic to a patient.Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.)
- A. Decrease in dysuria
- B. Decrease in urgency
- C. Decrease in frequency
- D. Decrease in prostate size
Correct Answer: A
Rationale: The correct answer is A: Decrease in dysuria. Antimuscarinic medications target muscarinic receptors, which are involved in the contraction of smooth muscle in the bladder. Dysuria, or painful urination, is a common symptom of overactive bladder or bladder spasms, which can be relieved by antimuscarinics. Choices B, C, and D are related to other urinary symptoms such as urgency, frequency, and prostate size, respectively, which are not directly targeted by antimuscarinics. Therefore, only a decrease in dysuria indicates therapeutic effects of the medication.
The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond?
- A. Privately ask the son to allow the patient to make his own health care decisions.
- B. Explain to the patient that he is responsible for his own decisions.
- C. Work with the team to negotiate informed consent.
- D. Avoid divulging information to the eldest son.
Correct Answer: C
Rationale: The correct answer is C: Work with the team to negotiate informed consent. In this scenario, the nurse should prioritize respecting the patient's cultural beliefs while also ensuring the patient's autonomy and right to make decisions about his own healthcare. By working with the healthcare team to negotiate informed consent, the nurse can involve both the patient and his eldest son in the decision-making process, ensuring that the patient's preferences are respected while also upholding ethical principles of patient autonomy and beneficence. This approach promotes collaboration and respect for cultural values while still safeguarding the patient's rights.
Choice A is incorrect because it does not involve the patient in the decision-making process and could undermine his autonomy. Choice B is incorrect as it disregards the patient's cultural beliefs and preferences. Choice D is incorrect as it may violate the patient's right to information and involvement in his own care.
The nurse is providing nutrition education to a Korean patient using the five food groups. In doing so, what should be the focus of the teaching?
- A. Discouraging the patient’s ethnic food choices
- B. Changing the patient’s diet to a more conventional American diet
- C. Including racial and ethnic practices with food preferences of the patient
- D. Comparing the patient’s ethnic preferences with American dietary choices
Correct Answer: C
Rationale: The correct answer is C because it emphasizes cultural competence and respect for the patient's background. By including racial and ethnic practices with food preferences of the patient, the nurse can provide tailored and relevant nutrition education. This approach promotes inclusivity and acknowledges the importance of cultural traditions in dietary habits. Choices A and B are incorrect as they disregard the patient's cultural background and may lead to cultural insensitivity. Choice D is also incorrect as it focuses on comparison rather than understanding and incorporating the patient's unique cultural context. Overall, choice C aligns with patient-centered care and facilitates effective communication and trust between the nurse and the patient.