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An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding?
- A. The patients hearing is likely normal.
- B. The patient is at risk for tinnitus.
- C. The patient likely has otosclerosis.
- D. The patient likely has sensorineural hearing loss. Chapter 69: Select Neuro Topics: Trigeminal Neuralgia & Bell’s Palsy
Correct Answer: A
Rationale: The correct answer is A: The patient's hearing is likely normal. This interpretation is based on the normal Rinne test result, where air-conducted sound is expected to be louder than bone-conducted sound. This finding indicates that the patient has intact air conduction and no significant conductive hearing loss. Option B is incorrect because tinnitus is not directly related to the Rinne test results. Option C is incorrect as otosclerosis would typically present with abnormal Rinne test results showing bone-conducted sound to be louder. Option D is incorrect as sensorineural hearing loss would not typically affect the Rinne test results in this way.
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A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
- A. Not until the drain is removed
- B. On the second postoperative day
- C. Now, if you wash gently with soap and water
- D. Seven days after your surgery
Correct Answer: A
Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications.
Summary:
B: On the second postoperative day - Too early, the drain needs to be removed first.
C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering.
D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.
A patient is receiving opioids for pain. Which bowel assessment is a priority?
- A. Clostridium difficile
- B. Constipation
- C. Hemorrhoids
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications.
Incorrect choices:
A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use.
C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment.
D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.
The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify?
- A. Helping the family to understand why the patient needs to be sedated
- B. Making arrangements to promptly move the patient to an acute-care facility
- C. Explaining to the family that death is near and the patient needs around-the-clock nursing care
- D. Teaching family members how to interact with, and ensure safety for, the patient with impaired cognition
Correct Answer: D
Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being.
Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.
A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
- A. Throw the catheter way and begin again.
- B. Fill the balloon with the recommended sterile water.
- C. Remove the catheter, wipe with alcohol, and reinsert after lubrication.
- D. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
Correct Answer: C
Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications.
Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
- A. Hold the shaft of the penis at a 60-degree angle.
- B. Hold the shaft of the penis with the dominant hand.
- C. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
- D. Cleanse the meatus with circular strokes beginning at the meatus and working outward.
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.