Nokea
The nurse is caring for a patient who is two days postoperative with an ileal conduit, and the patient will not look at the stoma or participate in care and insists that no one but the ostomy nurse specialist care for the stoma. Which of the following nursing diagnoses best reflects the data that the nurse has obtained?
- A. Anxiety related to threat to current status (effects of procedure on lifestyle)
- B. Disturbed body image related to alteration in self-perception
- C. Ineffective coping related to insufficient sense of control
- D. Ineffective denial related to ineffective coping strategies (denial of altered body function)
Correct Answer: B
Rationale: The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient, or that ineffective coping is a result of an insufficient sense of control. The patient's insistence that only the ostomy nurse care for the stoma indicates that denial is not present.
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The nurse is caring for a patient with renal calculi, gross hematuria, and severe colicky left flank pain. Which of the following actions is priority at this time?
- A. Encourage oral fluid intake.
- B. Administer prescribed analgesics.
- C. Monitor temperature every 4 hours.
- D. Give antiemetics as needed for nausea.
Correct Answer: B
Rationale: Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.
The nurse is admitting a patient with acute glomerulonephritis. Which of the following assessments is most important for the nurse to include?
- A. Recent sore throat and fever
- B. History of high blood pressure
- C. Frequency of bladder infections
- D. Family history of kidney stones
Correct Answer: A
Rationale: Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, urinary tract infection (UTI), or kidney stones.
The nurse is caring for a young adult female patient who is diagnosed with polycystic kidney disease. Which of the following information should the nurse include in teaching at this time?
- A. Importance of genetic counselling
- B. Complications of renal transplantation
- C. Methods for treating persistent and severe pain
- D. Differences between hemodialysis and peritoneal dialysis
Correct Answer: A
Rationale: Because a young female patient may be considering having children, the nurse should include information about genetic counselling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has persistent pain.
Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?
- A. Foul-smelling urine
- B. Complaint of flank pain
- C. Blood pressure 88/45 mm Hg
- D. Temperature 37.8°C (100°F)
Correct Answer: C
Rationale: Low blood pressure (88/45 mm Hg) indicates potential septic shock, a life-threatening complication of pyelonephritis, requiring urgent intervention. Foul-smelling urine, flank pain, and a mild fever are common findings in pyelonephritis but are less critical unless accompanied by systemic signs like hypotension.
A female patient asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which of the following interventions is best to include in the care plan?
- A. Assist the patient to the bathroom q3hr.
- B. Place a commode at the patient's bedside.
- C. Demonstrate how to perform the Credé manoeuvre.
- D. Teach the patient how to perform Kegel exercises.
Correct Answer: D
Rationale: Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé manoeuvre is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.