Nokea
The dying patient and family have many interrelated psychosocial and physical care needs. Which ones can the nurse begin to manage with the patient and family (select all that apply)?
- A. Anxiety
- B. Fear of pain
- C. The dying process
- D. Anger toward the nurse.
Correct Answer: A
Rationale: The nurse can address anxiety, fear of pain, and the dying process through education, medication, and emotional support, while anger toward the nurse might require conflict resolution strategies.
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While on a hiking trip, Mr. Jones states that a branch of a tree struck his eye. Part of the branch remains lodged in the eye, and the eyelid is bleeding. Appropriate emergency treatment would include
- A. covering the eye with a protective shield
- B. encouraging Mr. Jones to hold his eye closed tightly
- C. applying a pressure dressing to the eye
- D. removing the foreign body and applying a sterile dressing
Correct Answer: A
Rationale: Covering the eye with a protective shield prevents further injury while awaiting professional medical evaluation and removal of the foreign object.
A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?
- A. Restrict the client's fluid intake.
- B. Assess the client's respiratory status.
- C. Administer diuretics as ordered.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's respiratory status. The first action should be to assess the client's respiratory status as the weight gain could indicate fluid retention leading to pulmonary congestion, a common complication in heart failure. By assessing the respiratory status, the nurse can determine if there are signs of respiratory distress such as increased work of breathing, crackles, or shortness of breath. This assessment will help in identifying any immediate need for interventions such as oxygen therapy or diuretics. Restricting fluid intake (choice A) is important but not the first step. Administering diuretics (choice C) should be based on assessment findings. Notifying the healthcare provider (choice D) can be done after assessing the client's respiratory status.
What is the side effect caused by tyramine in foods when taking an MAOI inhibitor?
- A. Cardiac dysrrhythmias
- B. Thyroid storm
- C. Hypertensive crisis
- D. Rhabdomyolysis
Correct Answer: C
Rationale: Tyramine interacts with MAOIs to cause a dangerous rise in blood pressure, known as hypertensive crisis.
During a shower three days ago, Jeremy Robb, 19, discovered a firm lump in his left testis. He went to the student health center at his university, was referred to a local physician and was admitted to the hospital for a left orchiectomy and lymph node resection. Risk factors for cancer of the testes include:
- A. smoking.
- B. undescended testicle.
- C. multiple sex partners.
- D. genital trauma.
Correct Answer: B
Rationale: Smoking has been linked to cancer of the lungs, bladder, and pancreas, but has not been linked directly to cancer of the testes. Males who had undescended testicle(s) have been found to have a higher incidence of cancer of the testes later. It is theorized that the internal heat the testes are exposed to while in the abdomen causes the damage to the testes. Multiple sex partners is a risk for genital warts, AIDS, and sexually transmitted diseases, but has not been shown to be a risk for cancer of the testes. Genital trauma more likely causes bladder and ureteral damage.
During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?
- A. Dirty carpets requiring vacuuming
- B. Expired food found in the refrigerator
- C. Outdated medications stored in the kitchen
- D. Presence of multiple cats in the home
Correct Answer: B
Rationale: The correct answer is B (Expired food found in the refrigerator) because it poses a potential health risk to the client. Expired food can lead to foodborne illnesses, especially for an older adult post-surgery. Dirty carpets (choice A) may not directly impact the client's health. Outdated medications (choice C) can be addressed by the nurse without additional referrals. The presence of multiple cats (choice D) may be a concern for allergies or cleanliness, but it is not as urgent as expired food in terms of health risks.