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In the assessing the health condition of the preganant patient, Nurse Vera should focus on the _________.
- A. last menstrual period
- B. number of days of menstruation
- C. age of patient during menarche
- D. amount of menstrual flow
Correct Answer: A
Rationale: Nurse Vera should focus on the last menstrual period when assessing the health condition of the pregnant patient because it is crucial for determining the estimated due date of the pregnancy. Knowing the date of the last menstrual period allows healthcare providers to calculate the gestational age of the fetus, monitor the progress of the pregnancy, and identify any potential issues or complications that may arise. Additionally, the last menstrual period is necessary for accurate dating of the pregnancy and scheduling prenatal care visits and screenings. By focusing on the last menstrual period, Nurse Vera can gather important information that will guide the management and care of the pregnant patient.
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A patient receiving palliative care for end-stage heart failure experiences severe fatigue and limited mobility. What intervention should the palliative nurse prioritize to promote the patient's comfort and quality of life?
- A. Recommend initiating physical therapy to improve mobility and strength.
- B. Encourage the patient to conserve energy and avoid unnecessary activities.
- C. Prescribe stimulant medications to alleviate fatigue and increase energy levels.
- D. Refer the patient to a nutritionist for dietary modifications to boost energy.
Correct Answer: B
Rationale: In this scenario, the palliative nurse should prioritize encouraging the patient to conserve energy and avoid unnecessary activities (Option B). End-stage heart failure can lead to severe fatigue and limited mobility, making it essential for the patient to conserve energy to prevent exacerbating symptoms and improve quality of life. Engaging in physical therapy (Option A) may not be suitable for a patient experiencing severe fatigue, as it can further drain energy reserves. Prescribing stimulant medications (Option C) may have limited effectiveness and potential side effects. Referring the patient to a nutritionist for dietary modifications (Option D) is important for overall health but may not directly address the immediate comfort and quality of life concerns related to fatigue and limited mobility. Helping the patient prioritize energy conservation will allow them to use their limited energy for essential activities, leading to a more comfortable and fulfilling experience while receiving palliative care for end-stage heart failure.
A patient is prescribed a proton pump inhibitor (PPI) for the treatment of peptic ulcer disease. Which adverse effect should the nurse monitor closely in the patient?
- A. Constipation
- B. Hypokalemia
- C. Diarrhea
- D. Clostridium difficile infection
Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) are commonly prescribed for conditions involving excessive stomach acid production, such as peptic ulcer disease. One of the potential adverse effects of PPIs, such as omeprazole or pantoprazole, is the risk of hypokalemia. Hypokalemia is a condition characterized by low levels of potassium in the bloodstream. Prolonged use of PPIs can inhibit the absorption of potassium in the intestines, leading to a decrease in potassium levels in the body. Hypokalemia can present with symptoms such as muscle weakness, fatigue, irregular heartbeat, and in severe cases, it can result in life-threatening complications like cardiac arrhythmias. Therefore, it is essential for the nurse to closely monitor the patient for signs and symptoms of hypokalemia while on PPI therapy, especially if the patient is at risk for developing electrolyte imbalances.
A retired nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the, the nurse would probably be covered by
- A. Her homeowner's insurance
- B. National Care Act
- C. Her automobile insurance
- D. The Good Samaritan Law
Correct Answer: D
Rationale: The Good Samaritan Law offers legal protection to individuals who voluntarily provide assistance at the scene of an emergency or accident. These laws vary by state, but generally, they grant immunity from civil liability for the individual providing aid as long as they act in good faith and without expectation of compensation. In this case, the retired nurse who stopped to help in the emergency at the scene of an accident would likely be covered by the Good Samaritan Law, protecting her from being sued by the injured party for any unintended consequences of her efforts to assist.
One morning during rounds, Nurse Myra noticed that Marlene was unduly sad. The nurse 's BEST way of communicating her concern is _______.
- A. whatever it is, you lift it up to God
- B. saying you are sad again, that is bad for your health
- C. telling Marlene to stop worrying, everything will be okay
- D. placing her hand over Marlene 's shoulder and asking why the sad face
Correct Answer: D
Rationale: Placing her hand over Marlene's shoulder and asking why the sad face is the best way for Nurse Myra to communicate her concern. This approach shows empathy and creates a safe space for Marlene to open up about her feelings. By using physical touch and showing genuine interest in Marlene's well-being, Nurse Myra can effectively address the situation and provide appropriate support or guidance as needed. Simply dismissing Marlene's feelings (option B and C) or resorting to religious advice (option A) may not effectively address the underlying cause of Marlene's sadness. It is important in situations like this to show empathy, compassion, and a willingness to listen in order to provide the best support for the individual in distress.
What is the PRIORITY of care for patient diagnosed with Guillain-Barre Syndrome?
- A. Maintenance of respiratory function
- B. Prevention of decubitus
- C. Control of urinary tract infection
- D. Replacement of fluid and electrolytes
Correct Answer: A
Rationale: The priority of care for a patient diagnosed with Guillain-Barre Syndrome is the maintenance of respiratory function. Guillain-Barre Syndrome can cause paralysis, including respiratory muscles, leading to respiratory failure. Ensuring adequate ventilation and oxygenation is crucial to prevent complications such as respiratory failure and the need for mechanical ventilation. Monitoring for signs of respiratory distress, such as shortness of breath, decreased oxygen saturation, and diminished lung sounds, is essential in providing prompt intervention and support for the patient's respiratory needs. Other aspects of care, such as prevention of decubitus ulcers, control of urinary tract infections, and replacement of fluid and electrolytes, are also important but not as immediate or life-threatening as ensuring adequate respiratory function in these patients.