Nokea
The nurse is caring for patients with ostomies.In which ostomy location will the nurse expect very liquid stool to be present?
- A. Sigmoid
- B. Transverse
- C. Ascending
- D. Descending
Correct Answer: C
Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.
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A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
- A. Administer antidiarrheal medications on a scheduled basis, as ordered.
- B. Encourage the patient to eat three balanced meals and a snack at bedtime.
- C. Increase the patients oral fluid intake.
- D. Encourage the patient to increase his or her activity level.
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
- A. Reassure the patient that she will still be able to have children.
- B. Reassure the patient that she does not have to have sex to be feminine.
- C. Reassure the patient that you know how she is feeling and that you feel her anxiety and pain.
- D. Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm.
Correct Answer: B
Rationale: The correct answer is B: Reassure the patient that she does not have to have sex to be feminine.
Rationale:
1. Acknowledges patient's feelings: By reassuring the patient that she does not have to have sex to be feminine, the nurse validates the patient's emotions and concerns.
2. Addresses societal norms: This intervention challenges societal stereotypes that equate femininity solely with reproductive capabilities.
3. Promotes self-acceptance: Encouraging the patient to embrace her femininity beyond physical aspects fosters self-acceptance and self-worth.
4. Supports holistic care: Recognizing the multifaceted nature of femininity shows a holistic approach to addressing the patient's body image issues.
Summary:
A, C, and D are incorrect as they do not directly address the patient's specific concerns about her body image and femininity. Choice B is the most appropriate intervention as it validates the patient's feelings and challenges societal norms, promoting self-acceptance and holistic care
A nurse practitioner assesses the patient and diagnoses Gardnerella vaginalis. What would be the most appropriate nursing action at this time?
- A. Advise the patient that this is an overgrowth of normal vaginal flora.
- B. Discuss the effect of this diagnosis on the patients fertility.
- C. Document the vaginal discharge as normal.
- D. Administer acyclovir as ordered.
Correct Answer: A
Rationale: The correct answer is A: Advise the patient that this is an overgrowth of normal vaginal flora. This is correct because Gardnerella vaginalis is a bacteria associated with bacterial vaginosis, which is an overgrowth of normal vaginal flora. By advising the patient of this, the nurse practitioner can provide education on the condition and treatment options.
B: Discussing the effect of this diagnosis on the patient's fertility is incorrect as Gardnerella vaginalis is not typically associated with fertility issues.
C: Documenting the vaginal discharge as normal is incorrect as Gardnerella vaginalis is indicative of an abnormal vaginal flora imbalance.
D: Administering acyclovir as ordered is incorrect as acyclovir is an antiviral medication used to treat herpes simplex virus infections, not bacterial vaginosis caused by Gardnerella vaginalis.
The nurse is caring for a patient who is to begin receiving external radiation for a malignant tumor of the neck. While providing patient education, what potential adverse effects should the nurse discuss with the patient?
- A. Impaired nutritional status
- B. Cognitive changes
- C. Diarrhea
- D. Alopeci
Correct Answer: A
Rationale: The correct answer is A: Impaired nutritional status. Radiation therapy to the neck can lead to mucositis, dysphagia, and taste changes, which can impair the patient's ability to eat and maintain adequate nutrition. This can lead to weight loss, weakness, and delayed wound healing. Discussing this potential adverse effect with the patient is crucial for proactive management.
Choice B: Cognitive changes, and Choice C: Diarrhea are less likely to be direct adverse effects of radiation therapy to the neck. Cognitive changes are more commonly associated with brain radiation, while diarrhea is a more common side effect of abdominal radiation.
Choice D: Alopecia is a side effect of chemotherapy, not radiation therapy. Radiation therapy does not typically cause hair loss unless it is in the treatment field. Therefore, discussing alopecia with the patient receiving radiation for a malignant neck tumor is not a priority.
After the completion of testing, a childs allergies have been attributed to her familys cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action?
- A. Removing the cat from the familys home
- B. Administering OTC antihistamines to the child regularly
- C. Keeping the cat restricted from the childs bedroom
- D. Maximizing airflow in the house
Correct Answer: A
Rationale: The correct answer is A: Removing the cat from the family's home. This is the most effective way to prevent allergic reactions in the child. By removing the source of allergens (cat), the child will be exposed to fewer allergens, leading to a reduction in symptoms.
B: Administering OTC antihistamines treats symptoms but does not address the underlying cause of the allergy.
C: Keeping the cat restricted from the child's bedroom helps reduce exposure, but allergens can still spread throughout the house.
D: Maximizing airflow may help reduce allergens in the air but does not eliminate the source of the allergy.