Nokea
The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the ff. is the best evidence that the teaching has been effective?
- A. The patient states that he will be careful to avoid injury.
- B. The patient can list signs and symptoms of bleeding.
- C. The patient uses an electric razor instead of his safety razor.
- D. The patient states when he should call the doctor.
Correct Answer: C
Rationale: The correct answer is C because using an electric razor instead of a safety razor demonstrates understanding of the risk of injury associated with thrombocytopenia. This action shows practical application of the teaching to prevent bleeding. Choice A only indicates awareness but not necessarily action. Choice B shows knowledge but not necessarily application. Choice D is related to general healthcare knowledge but not directly linked to bleeding prevention in thrombocytopenia.
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For a patient who is being discharged on digoxin, the nurse should include which of the ff. in an explanation to the patient on the signs and symptoms of digoxin toxicity?
- A. Poor appetite
- B. Halos around lights
- C. Constipation
- D. Tachycardia
Correct Answer: B
Rationale: The correct answer is B: Halos around lights. Digoxin toxicity can cause visual disturbances like seeing halos around lights, which is a common symptom. This is due to its effect on the eyes. Poor appetite (choice A) is a common side effect but not specific to toxicity. Constipation (choice C) is not a typical sign of digoxin toxicity. Tachycardia (choice D) is more commonly associated with digoxin toxicity, but visual disturbances like halos around lights are more specific and should be explained to the patient.
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
- A. Consider cultural differences during this assessment.
- B. Ask the patient to make eye contact to determine her affect.
- C. Continue with the interview and document that the patient is depressed.
- D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship.
Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James’ neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow.
Incorrect choices:
B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties.
C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties.
D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.
In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:
- A. Accepting the denial.
- B. Supporting the denial.
- C. Confronting the denial.
- D. Interpreting the denial.
Correct Answer: C
Rationale: The correct response is C: Confronting the denial. Denial is a defense mechanism that can hinder the client's acceptance and coping with the situation. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and process their feelings. Accepting (A) or supporting (B) the denial would enable the client to avoid facing reality. Interpreting (D) the denial may lead to miscommunication or misunderstanding. Confronting the denial encourages the client to address their emotions and move towards acceptance and healing.
A patient has allergic rhinitis. In planning care for the patient, the nurse understands that if the patient does not remain compliant with the treatment regimen, the patient is at risk for developing which of the following?
- A. Sinusitis
- B. Lymphadenopathy
- C. Anaphylaxis
- D. Angioedema
Correct Answer: A
Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications.
Summary of other choices:
B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis.
C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis.
D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.