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An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
- A. Functional urinary incontinence
- B. Urge urinary incontinence
- C. Impaired skin integrity
- D. Urinary retention
Correct Answer: B
Rationale: Correct Answer: B - Urge urinary incontinence
Rationale:
1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence.
2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage.
Incorrect Choices:
A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void.
C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis.
D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.
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To decrease glandular cellular activity and prostate size, an 83-year-old patient has been prescribed finasteride (Proscar). When performing patient education with this patient, the nurse should be sure to tell the patient what?
- A. Report the planned use of dietary supplements to the physician.
- B. Decrease the intake of fluids to prevent urinary retention.
- C. Abstain from sexual activity for 2 weeks following the initiation of treatment.
- D. Anticipate a temporary worsening of urinary retention before symptoms subside.
Correct Answer: A
Rationale: Step 1: Finasteride is a medication that works by decreasing glandular cellular activity and reducing prostate size.
Step 2: Dietary supplements can interact with finasteride, potentially affecting its effectiveness or causing adverse effects.
Step 3: Reporting the planned use of dietary supplements to the physician ensures proper monitoring and adjustment of the treatment plan.
Step 4: This communication promotes patient safety and optimal therapeutic outcomes.
Therefore, choice A is correct as it emphasizes the importance of informing the physician about dietary supplement use to ensure the efficacy and safety of finasteride. Choices B, C, and D are incorrect as they do not directly relate to the mechanism of action or specific considerations of finasteride therapy.
The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patients risk of hypercalcemia?
- A. Stool softeners are contraindicated.
- B. Laxatives should be taken daily.
- C. Consume 2 to 4 L of fluid daily.
- D. Restrict calcium intake.
Correct Answer: C
Rationale: Rationale: Option C is correct because adequate hydration helps prevent hypercalcemia by promoting the excretion of excess calcium in the urine. This reduces the risk of calcium buildup in the blood. Consuming 2 to 4 liters of fluid daily ensures proper hydration, which is crucial for patients at risk for hypercalcemia. Stool softeners (Option A) are not contraindicated and can help prevent constipation, which may be a side effect of some cancer treatments. Laxatives (Option B) should not be taken daily as they can lead to dehydration and electrolyte imbalances. Restricting calcium intake (Option D) is not the primary intervention for preventing hypercalcemia; rather, maintaining adequate hydration is key.
A patient has just returned to the postsurgical unit from post-anesthetic recovery after breast surgery for removal of a malignancy. What is the most likely major nursing diagnosis to include in this patients immediate plan of care?
- A. Acute pain related to tissue manipulation and incision
- B. Ineffective coping related to surgery
- C. Risk for trauma related to post-surgical injury
- D. Chronic sorrow related to change in body image
Correct Answer: A
Rationale: The correct answer is A: Acute pain related to tissue manipulation and incision. This is the most likely major nursing diagnosis because post-surgical pain is a common and expected occurrence after breast surgery. The patient is likely to experience pain due to tissue manipulation and incision during the surgery. Addressing acute pain is crucial for the patient's comfort, well-being, and overall recovery.
Choice B (Ineffective coping related to surgery) may be a secondary nursing diagnosis, but acute pain takes priority as it directly impacts the patient's immediate comfort and recovery. Choice C (Risk for trauma related to post-surgical injury) is not the most appropriate nursing diagnosis since the patient has already undergone surgery and is not at risk for further injury at this point. Choice D (Chronic sorrow related to change in body image) is not the most immediate concern post-surgery; addressing acute pain is more critical.
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
- A. You know, you are getting older now and we change as we get older.
- B. The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry.
- C. There is a gradual thickening of the lens of the eye and it can limit the eyes ability for accommodation.
- D. The eye gets shorter, back to front, as we age and it changes how we see things.
Correct Answer: C
Rationale: The correct answer is C because it accurately explains the physiological change in the eye that leads to the need for bifocals. As individuals age, there is a gradual thickening of the lens of the eye, which affects the eye's ability to accommodate for near vision. This thickening makes it harder for the eye to focus on close objects, necessitating the use of bifocals to correct this near vision issue.
Choices A, B, and D are incorrect because they do not provide a scientifically accurate explanation for the need for bifocals in older individuals. Option A is dismissive and does not address the specific change in the eye that leads to the need for bifocals. Option B implies aging as a general concept without specifying the relevant change in the eye. Option D incorrectly states that the eye gets shorter as we age, which is not the reason for needing bifocals.
A nurse is assessing a patient’s ethnohistory.Which question should the nurse ask?
- A. What language do you speak at home?
- B. How different is your life here from back home?
- C. Which caregivers do you seek when you are sick?
- D. How different is what we do from what your family does when you are sick?
Correct Answer: B
Rationale: The correct answer is B because it directly addresses the patient's ethnohistory by asking about the differences in their life here compared to back home. This question helps the nurse understand the patient's cultural background, beliefs, and practices. Option A focuses solely on language, which is not sufficient to understand ethnohistory. Option C inquires about caregivers during sickness, which is important but does not specifically relate to ethnohistory. Option D compares treatment approaches, which is relevant but doesn't explore the broader cultural context as effectively as option B.