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An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
- A. Apply an ice pack or heating pad PRN to relieve pain and pruritis
- B. Avoid skin contact with water whenever possible
- C. Apply phototherapy PRN
- D. Avoid rubbing or scratching the affected area
Correct Answer: D
Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area
Rationale:
1. Rubbing or scratching can further damage the already compromised skin integrity.
2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing.
3. This intervention promotes skin healing and prevents worsening of the condition.
Summary:
A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity.
B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity.
C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.
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A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?
- A. Assessment of peripheral nervous function
- B. Assessment of cranial nerve function
- C. Assessment of nutritional status
- D. Assessment of respiratory status
Correct Answer: C
Rationale: The correct answer is C: Assessment of nutritional status. Cachexia is a complex metabolic syndrome characterized by weight loss, muscle wasting, and weakness commonly seen in cancer patients. Assessing the patient's nutritional status is crucial to address the underlying causes of cachexia and to develop an appropriate management plan. This assessment includes evaluating dietary intake, weight changes, body composition, and nutritional deficiencies.
Choice A: Assessment of peripheral nervous function is not the priority in this case as cachexia is primarily related to metabolic and nutritional issues rather than peripheral nervous system dysfunction.
Choice B: Assessment of cranial nerve function is also not the priority since cachexia is not directly associated with cranial nerve dysfunction.
Choice D: Assessment of respiratory status may be important in general patient care, but in this case, addressing the underlying nutritional issues that are contributing to cachexia should be the priority.
A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery?
- A. Teaching the patient about options for eye prostheses
- B. Teaching the patient to estimate depth and distance with the use of one eye
- C. Assessing and addressing the patients emotional needs
- D. Teaching the patient about his post-discharge medication regimen
Correct Answer: C
Rationale: The correct answer is C: Assessing and addressing the patient's emotional needs. This should be prioritized because the patient has undergone a traumatic experience losing their eye due to a workplace accident. Emotions such as fear, anxiety, and grief are common postoperatively. Addressing these emotional needs is crucial for the patient's overall well-being and recovery. Options A, B, and D are important aspects of care but not the priority in this situation. Teaching about eye prostheses, depth perception, and medication regimen can be addressed once the patient's emotional needs are stabilized.
A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
- A. Maintenance of good perineal hygiene
- B. Prevention of constipation
- C. Increased fluid intake for 2 weeks postpartum
- D. Performance of pelvic muscle exercises Chapter 58: Breast Cancer: Breast cancer – risks factors, Diagnostic tests and management, Self Breast Exam, Perioperative care: Complications, Rehab, Discharge teaching
Correct Answer: D
Rationale: The correct answer is D, performance of pelvic muscle exercises. Pelvic muscle exercises, also known as Kegel exercises, help strengthen the pelvic floor muscles which support the bladder, uterus, and bowel. By strengthening these muscles, the risk of developing cystocele, rectocele, and uterine prolapse postpartum is reduced. It is a proactive approach to prevent these conditions.
Choice A, maintenance of good perineal hygiene, is important for preventing infections but does not specifically address the risk of pelvic organ prolapse. Choice B, prevention of constipation, is also important but does not directly target the muscle weakness that contributes to prolapse. Choice C, increased fluid intake for 2 weeks postpartum, is not as effective in preventing prolapse as pelvic muscle exercises.
In summary, pelvic muscle exercises are the most appropriate recommendation as they directly address strengthening the muscles that support the pelvic organs, reducing the risk of prolapse postpartum.
The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
- A. Observe the color of gastric contents.
- B. Verify tube placement before feeding.
- C. Add blue food coloring to the enteral formula.
- D. Run the formula over 12 hours to decrease overload.
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.
Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is
- A. varied depending on the stage of gestation.
- B. increased throughout pregnancy and the postpartum period.
- C. decreased throughout pregnancy and the postpartum period.
- D. should not change because the fetus produces its own insulin.
Correct Answer: A
Rationale: Rationale:
1. Insulin needs change during pregnancy due to hormonal changes.
2. During the first trimester, insulin needs may decrease.
3. During the second and third trimesters, insulin needs increase.
4. Postpartum, insulin needs return to pre-pregnancy levels.
Therefore, choice A is correct as insulin needs vary based on gestational stage. Choices B, C, and D are incorrect because insulin needs do not uniformly increase or decrease throughout pregnancy or due to fetal insulin production.