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The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy when it is scheduled at what time?
- A. Immediately after meals
- B. In the morning
- C. Before bedtime
- D. In the early evening
Correct Answer: B
Rationale: The correct answer is B: In the morning. This is because scheduling physical therapy in the morning allows the patient to benefit from increased energy levels and improved muscle strength and function after a night of rest. Morning sessions can also help set a positive tone for the rest of the day.
Choice A: Immediately after meals can lead to discomfort and potential complications like indigestion or reflux.
Choice C: Before bedtime may be too late in the day when fatigue levels are higher and may disrupt sleep patterns.
Choice D: In the early evening may be less effective as fatigue accumulates throughout the day, and the patient may not have the same level of energy and focus as in the morning.
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A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
- A. Maintenance of good perineal hygiene
- B. Prevention of constipation
- C. Increased fluid intake for 2 weeks postpartum
- D. Performance of pelvic muscle exercises Chapter 58: Breast Cancer: Breast cancer – risks factors, Diagnostic tests and management, Self Breast Exam, Perioperative care: Complications, Rehab, Discharge teaching
Correct Answer: D
Rationale: The correct answer is D, performance of pelvic muscle exercises. Pelvic muscle exercises, also known as Kegel exercises, help strengthen the pelvic floor muscles which support the bladder, uterus, and bowel. By strengthening these muscles, the risk of developing cystocele, rectocele, and uterine prolapse postpartum is reduced. It is a proactive approach to prevent these conditions.
Choice A, maintenance of good perineal hygiene, is important for preventing infections but does not specifically address the risk of pelvic organ prolapse. Choice B, prevention of constipation, is also important but does not directly target the muscle weakness that contributes to prolapse. Choice C, increased fluid intake for 2 weeks postpartum, is not as effective in preventing prolapse as pelvic muscle exercises.
In summary, pelvic muscle exercises are the most appropriate recommendation as they directly address strengthening the muscles that support the pelvic organs, reducing the risk of prolapse postpartum.
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
- A. Attach the condom prior to erection.
- B. A condom may be reused with the same partner if ejaculation has not occurred.
- C. Use skin lotion as a lubricant if alternatives are unavailable.
- D. Hold the condom by the cuff upon withdrawal.
Correct Answer: D
Rationale: The correct answer is D: Hold the condom by the cuff upon withdrawal. This is important because holding the condom by the cuff helps prevent any potential spillage of bodily fluids. During withdrawal, holding the condom by the base prevents it from slipping off and minimizes the risk of exposure to sexually transmitted infections.
Explanation of why other choices are incorrect:
A: Attaching the condom prior to erection is incorrect as it may lead to breakage or slipping off during intercourse.
B: Reusing a condom with the same partner is highly discouraged due to the risk of breakage, reduced effectiveness, and potential exposure to infections.
C: Using skin lotion as a lubricant is not recommended as it can degrade the condom material, increasing the risk of breakage.
A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the patients metastatic brain disease?
- A. Chronic pain
- B. Respiratory distress
- C. Fixed pupils
- D. Personality changes
Correct Answer: D
Rationale: The correct answer is D: Personality changes. Metastases to the brain can affect cognitive function and behavior, leading to personality changes. This is due to the impact on specific areas of the brain responsible for personality and behavior. Chronic pain (A) is more commonly associated with advanced cancer and not specific to brain metastases. Respiratory distress (B) is more likely related to lung cancer itself, not brain metastases. Fixed pupils (C) may indicate brainstem involvement, but personality changes are a more direct and common manifestation of brain metastases.
An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
- A. Functional urinary incontinence
- B. Urge urinary incontinence
- C. Impaired skin integrity
- D. Urinary retention
Correct Answer: B
Rationale: Correct Answer: B - Urge urinary incontinence
Rationale:
1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence.
2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage.
Incorrect Choices:
A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void.
C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis.
D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
- A. Have the patient void and have bowel movements using a commode rather than toilet.
- B. Count and inspect each perineal pad that the patient uses.
- C. Swab the patients perineum for the presence of blood at least once per shift.
- D. Leave the patients perineum open to air to facilitate inspection.
Correct Answer: B
Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage.
A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring.
C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads.
D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.