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In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?
- A. Weight increases.
- B. Weight decreases.
- C. Weight does not change.
- D. Weight fluctuates daily.
Correct Answer: C
Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance.
A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain.
B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss.
D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.
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A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurses best response?
- A. I can only imagine how you feel. Would you like to talk about it?
- B. Lets find a quiet spot and Ill teach you a few coping strategies.
- C. Thats the same way that most patients who have a chronic illness feel.
- D. Do you think that maybe you could be managing things more efficiently?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship.
Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.
A patient with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection?
- A. Clotrimazole (Gyne-Lotrimin)
- B. Metronidazole (Flagyl)
- C. Podophyllin (Podofin)
- D. Acyclovir (Zovirax)
Correct Answer: D
Rationale: The correct answer is D: Acyclovir (Zovirax). Acyclovir is an antiviral medication specifically used to treat herpes infections, including genital herpes. It works by inhibiting the replication of the herpes virus, thereby suppressing symptoms and shortening the course of the infection. Clotrimazole (A) is an antifungal medication used to treat yeast infections, not effective against viral infections like herpes. Metronidazole (B) is an antibiotic used to treat bacterial infections, not effective against viruses. Podophyllin (C) is a topical treatment for genital warts caused by the human papillomavirus (HPV), not effective for herpes. Therefore, the correct choice is Acyclovir (D) for treating genital herpes exacerbation.
Before giving the patient an intermittent gastric tube feeding, what should the nurse do?
- A. Make sure that the tube is secured to the gown with a safety pin.
- B. Inject air into the stomach via the tube and auscultate.
- C. Have the tube feeding at room temperature.
- D. Check to make sure pH is at least 5
Correct Answer: B
Rationale: The correct answer is B because injecting air into the stomach via the tube and auscultating helps confirm the tube placement in the stomach before administering the feeding. This step ensures the safety of the patient by preventing accidental lung feeding.
Choice A is incorrect because securing the tube with a safety pin to the gown is not a standard practice and can lead to complications.
Choice C is incorrect because the temperature of the feeding does not affect the tube placement or safety.
Choice D is incorrect because checking the pH level is not a reliable method for verifying tube placement.
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment?
- A. Is she able to tell her family of negative test results?
- B. Does she have a sense of peace of mind and a purpose to her life?
- C. Can she let go of her husband so he can make a new life?
- D. Does she need time and space to bargain with God for a cure?
Correct Answer: B
Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty.
Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.
The hospice nurse has just admitted a new patient to the program. What principle guides hospice care?
- A. Care addresses the needs of the patient as well as the needs of the family.
- B. Care is focused on the patient centrally and the family peripherally.
- C. The focus of all aspects of care is solely on the patient.
- D. The care team prioritizes the patients physical needs and the family is responsible for the patients emotional needs.
Correct Answer: A
Rationale: The correct answer is A because hospice care is centered on a holistic approach that considers the physical, emotional, social, and spiritual needs of both the patient and their family. This principle recognizes that caring for a terminally ill patient involves supporting the entire family unit. Choice B is incorrect because family support is integral to hospice care. Choice C is incorrect because hospice care extends beyond just the patient to include their loved ones. Choice D is incorrect because the care team should address all aspects of care for both the patient and their family, not prioritize one over the other.