Nokea
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
- A. Maximize the patients fluid intake.
- B. Provide total parenteral nutrition (TPN).
- C. Keep the patients bed linens free of wrinkles.
- D. Provide the patient with snug clothing at all times.
Correct Answer: C
Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity.
A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity.
B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity.
D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.
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A hospice nurse is well aware of how difficult it is to deal with others pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?
- A. Inefficiency in the provision of care
- B. Excessive weight gain
- C. Emotional exhaustion
- D. Social withdrawal
Correct Answer: C
Rationale: The correct answer is C: Emotional exhaustion. Dealing with others' pain daily can lead to burnout and emotional exhaustion for the nurse. This can result in decreased empathy and effectiveness in providing care. Healthy practices such as self-care, setting boundaries, and seeking support can help prevent emotional exhaustion.
Choice A: Inefficiency in the provision of care is incorrect because emotional exhaustion may affect the quality of care but does not necessarily lead to inefficiency.
Choice B: Excessive weight gain is incorrect as it is not directly related to the emotional toll of dealing with others' pain.
Choice D: Social withdrawal is incorrect as it is a potential outcome of emotional exhaustion but not the primary concern in this scenario.
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?
- A. Assess the patient for additional signs and symptoms of Kaposis sarcoma.
- B. Review the patients most recent viral load and CD4+ count.
- C. Place the patient on respiratory isolation and inform the physician.
- D. Perform oral suctioning to reduce the patients risk for aspiration.
Correct Answer: C
Rationale: The correct answer is C: Place the patient on respiratory isolation and inform the physician. This is the most appropriate action because the patient is exhibiting symptoms that could be indicative of a potentially infectious respiratory condition, such as tuberculosis or pneumonia. Placing the patient on respiratory isolation helps prevent the spread of infection to others and protects healthcare workers. Informing the physician promptly allows for further evaluation and appropriate treatment.
Choice A is incorrect as Kaposi's sarcoma typically presents with skin lesions rather than respiratory symptoms. Choice B is incorrect as reviewing viral load and CD4+ count would not address the immediate concern of respiratory symptoms. Choice D is incorrect as oral suctioning is not the appropriate intervention for night sweats and coughing up blood.
A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis?
- A. Malleus
- B. Stapes
- C. Incus
- D. Tympanic membrane
Correct Answer: B
Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
- A. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence
- B. A patient with reflex incontinence with elevated blood pressure and pulse rate
- C. A patient with an indwelling catheter that has stool on the catheter tubing
- D. A patient who has just voided and needs a postvoid residual test
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention.
Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B.
Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B.
Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.
A nurse is completing an OASIS data set on apatient. The nurse works in which area?
- A. Home health
- B. Intensive care unit
- C. Skilled nursing facility
- D. Long-term care facility
Correct Answer: A
Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.