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The nurse is providing postoperative care to a patient who underwent a total abdominal hysterectomy 12 hours ago. Which of the following are appropriate nursing interventions? Select all that apply.
- A. Assist the patient with ambulation.
- B. Maintain the Foley catheter for 48 to 72 hours postoperatively.
- C. Monitor intake and output and characteristics of urin
- D. urinary tract infection
Correct Answer: A
Rationale: A. Assist the patient with ambulation: Encouraging early ambulation after surgery helps prevent complications such as blood clots, pneumonia, and pressure ulcers. It also promotes circulation and aids in the recovery process.
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What assessment finding suggests that a patient may have fibrocystic breast changes?
- A. green-tinged nipple discharge
- B. ongoing breast pain
- C. firm, ropy feel of the breast tissue under the skin
- D. peau d’orange appearance of the skin
Correct Answer: C
Rationale: Fibrocystic breast changes typically present with breast pain and a cyclic pattern of nodularity and/or lumps in the breast tissue. The characteristic assessment finding that suggests fibrocystic breast changes is the firm, ropy feel of the breast tissue under the skin. This texture is due to the presence of fibrous tissue and cysts within the breast, which can be felt during the physical examination. While nipple discharge and skin changes like peau d’orange can be associated with different breast conditions, the firm and ropy feel of the breast tissue is more specific to fibrocystic changes.
Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
- A. Risk for anxiety related to upcoming birth
- B. Risk for imbalanced nutrition related to NPO status
- C. Risk for altered family processes related to new addition to the family
- D. Risk for injury (maternal) related to altered sensations and positional or physical
changes
Correct Answer: D
Rationale: The priority nursing diagnosis for a patient in active labor should focus on ensuring the safety and well-being of the mother and the baby. "Risk for injury (maternal) related to altered sensations and positional or physical changes" is the most crucial diagnosis in this scenario as it directly addresses potential risks and complications that may occur during labor and delivery. This nursing diagnosis includes considerations for the physical changes the mother undergoes during labor, such as altered sensations and positioning, which can increase the risk of injury. By identifying and addressing this risk promptly, the nurse can help prevent potential harm to the mother and ensure a safe delivery process.
The nurse is planning a teaching session for staff on ethical theories. Which situation best reflects the Deontologic theory?
- A. Approving a physician-assisted suicide
- B. Supporting the transplantation of fetal tissue and organs
- C. Using experimental medications for the treatment of AIDS
- D. Initiating resuscitative measures on a 90-year-old patient with terminal cancer
Correct Answer: D
Rationale: Deontologic theory, also known as deontological ethics, focuses on the duty to follow moral rules and obligations regardless of the consequences. In this scenario, initiating resuscitative measures on a 90-year-old patient with terminal cancer reflects a commitment to upholding the duty to provide care and uphold the sanctity of life. Despite the patient's poor prognosis, the nurse is ethically bound to provide care according to established principles and guidelines, emphasizing duty over outcome. This aligns with the Deontologic theory's emphasis on following moral rules and obligations without consideration of the consequences.
Which goal is most appropriate for the collaborative problem of wound infection?
- A. The patient will not exhibit further signs of infection.
- B. Maintain the patient’s fluid intake at 1000 mL/8 hour.
- C. The patient will have a temperature of 98.6F within 2 days.
- D. Monitor the patient to detect therapeutic response to antibiotic therapy.
Correct Answer: A
Rationale: The most appropriate goal for the collaborative problem of wound infection is "The patient will not exhibit further signs of infection." This goal directly addresses the issue of controlling and resolving the infection within the wound, leading to the overall improvement in the patient's condition. By ensuring that the patient does not exhibit further signs of infection, healthcare providers can monitor the effectiveness of treatment interventions and prevent any complications that may arise from the infection spreading or worsening. In contrast, options B, C, and D are not directly related to addressing the wound infection itself, making them less appropriate goals for this specific problem.
A college-aged female patient states that she understands the risk of sexual assault with overdrinking. She asks the nurse what health risks are associated with excessive alcohol intake for her age. What diseases or conditions should the nurse include in her response? Select all that
apply
- A. Infertility
- B. Cancer of mouth
- C. Hypertension
- D. Brain shrinkage
Correct Answer: A
Rationale: A. Excessive alcohol intake is a risk factor for developing cancer, particularly cancers of the mouth, throat, esophagus, liver, and breast. Chronic alcohol use can increase the individual's susceptibility to these types of cancers.