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As the nurse and the dietitian review a female patient's diet plan with her, she shouts that with her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as well eat what she wants, because there is nothing she can do to help herself. Based on the patient's response, which patient problem does the nurse identify?
- A. The patient will not likely follow a prescribed diet due to anger.
- B. The patient does not understand the diet, and will likely have poor nutrition.
- C. The patient is in the grieving process, due to the probability she will die soon.
- D. The patient is feeling unable to cope, and feels helpless over having diabetes and kidney failure.
Correct Answer: D
Rationale: Ineffective coping due to the feeling of powerlessness against the multiorgan failure may result in aggressive or infantile behavior.
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The nurse assessing a patient who is taking furosemide finds an irregular pulse. This is likely a sign of which disorder?
- A. hypomagnesemia.
- B. hypernatremia.
- C. hypokalemia.
- D. hypercalcemia.
Correct Answer: C
Rationale: The loop diuretic prototype, furosemide affects electrolytes and causes hypokalemia; the deficiency of the electrolyte can cause arrhythmias and muscle weakness.
The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching, which aspect will the nurse emphasize about what the patient can expect after the procedure?
- A. Red drainage from the catheter
- B. Limited intake of fluids
- C. A sodium-restricted diet
- D. Incisional drainage
Correct Answer: A
Rationale: The patient and family need to know that hematuria is expected after prostatic surgery.
It is 2 days after a 42-year-old male patient's urinary diversion surgery. He continues to be critical of the hospital and the nursing care, even though the staff has spent time explaining the care to him. Which explanation is most likely for his behavior?
- A. He is angry about hospital policy.
- B. He is feeling neglected by the nursing staff.
- C. He is in denial of the effects of the surgery.
- D. He is reacting to the loss of self-esteem and altered body image.
Correct Answer: D
Rationale: Persons with altered body image may react to the loss of self-esteem by behaving in a critical or derogatory manner.
A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. Which nursing intervention does the nurse expect to see in the plan of care?
- A. Restrict fluids after the evening meal.
- B. Insert an indwelling catheter.
- C. Assist the patient to the bathroom every 6 hours.
- D. Apply absorbent incontinence pads.
Correct Answer: D
Rationale: Use of protective undergarments may help to keep the patient and the patient's clothing dry. Patients who are confused are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance.
A home health patient with end-stage renal disease (ESRD) verbalizes feeling helplessness related to this life-altering disease. Which nursing intervention would be most helpful?
- A. Ensure restricted protein intake to prevent nitrogenous product accumulation.
- B. Include the patient in making the plan of care.
- C. Counsel patient about end-of-life provisions.
- D. Write out a detailed schedule of health care provider's appointments.
Correct Answer: B
Rationale: Listen to the patient and allow time for discussion about concerns and the plan of care to return some sense of control. End-of-life discussions are premature and will not benefit the patient who is experiencing helplessness.