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The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?
- A. These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies.
- B. These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer.
- C. Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy.
- D. Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's symptoms, reassures monitoring, and addresses the cause. It validates his experience while offering a proactive approach. Choice B is incorrect as it dismisses the patient's symptoms and can cause distress. Choice C is incorrect because it generalizes the patient's experience and lacks individualized care. Choice D is incorrect as it may give false hope and oversimplifies the situation. A provides the best balance of empathy and information for the patient's well-being.
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The patient with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful?
- A. Maintain a prescribed carbohydrate intake.
- B. Eat fish at least 5 times per week.
- C. Limittransfat to less than 1%.
- D. Avoid high-fiber foods.
Correct Answer: B
Rationale: Correct Answer: B - Eat fish at least 5 times per week.
Rationale:
1. Fish is rich in omega-3 fatty acids, which are beneficial for heart health.
2. Eating fish frequently can help reduce the risk of cardiovascular diseases.
3. Consuming fish aligns with dietary recommendations for cardiovascular health.
Summary of Incorrect Choices:
A: Maintaining carbohydrate intake is important, but it may not specifically indicate success in cardiovascular disease management.
C: Limiting trans fats is crucial, but it alone may not indicate overall success in dietary management for cardiovascular disease.
D: Avoiding high-fiber foods is not recommended, as fiber is beneficial for heart health and overall well-being.
A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse notes significant urine leakage around the suprapubic tube. What is the nurses most appropriate action?
- A. Cleanse the skin surrounding the suprapubic tube.
- B. Inform the urologist of this finding.
- C. Remove the suprapubic tube and apply a wet-to-dry dressing.
- D. Administer antispasmodic drugs as ordered.
Correct Answer: B
Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage.
Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.
A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses?
- A. Prepare an advance directive.
- B. Designate a most responsible physician (MRP) early in the course of the disease.
- C. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association.
- D. Ensure that witnesses are present when he provides instruction.
Correct Answer: A
Rationale: The correct answer is A: Prepare an advance directive. This allows the patient to document their healthcare preferences in advance, ensuring their wishes are known and honored as the disease progresses. It provides clear instructions for healthcare providers and family members, reducing potential conflicts and ensuring the patient's autonomy is respected.
Choice B is incorrect as designating an MRP focuses on medical decision-making but may not capture the full range of the patient's care preferences. Choice C involves collaboration with an organization, which may not fully represent the patient's individual wishes. Choice D is incorrect as witnesses are not always necessary for providing instructions, and the presence of witnesses does not guarantee that the patient's wishes will be followed accurately.
The clinic nurse is performing a prenatal assessment on a pregnant patient at risk for preeclampsia. Which clinical sign would not present as a symptom of preeclampsia?
- A. Edema
- B. Proteinuria
- C. Glucosuria
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C, Glucosuria. Preeclampsia is characterized by hypertension, proteinuria, and edema. Glucosuria is not a typical symptom of preeclampsia. Glucosuria is more commonly associated with gestational diabetes, which is a separate condition from preeclampsia. Therefore, in a pregnant patient at risk for preeclampsia, the presence of glucosuria would not be indicative of preeclampsia. The other choices, edema, proteinuria, and hypertension, are all common clinical signs seen in patients with preeclampsia.
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
- A. Administration of the measles-mumps-rubella (MMR) vaccine
- B. Rapid administration of intravenous fluids
- C. Computed tomography with contrast solution
- D. Administration of nebulized bronchodilators
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient.
Incorrect choices:
A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans.
B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis.
D: Administration of nebulized bronchodil