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The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patients tumor, the nurse should implement measures to prevent what complication?
- A. Falls
- B. Audio hallucinations
- C. Respiratory depression
- D. Labile BP
Correct Answer: A
Rationale: The correct answer is A: Falls. A cerebellar tumor can affect coordination and balance, leading to an increased risk of falls. Measures to prevent falls include maintaining a clutter-free environment, using assistive devices, and providing supervision.
Choice B (Audio hallucinations) is incorrect as cerebellar tumors typically do not cause auditory hallucinations. Choice C (Respiratory depression) is incorrect as cerebellar tumors do not directly affect the respiratory system. Choice D (Labile BP) is incorrect as cerebellar tumors are not typically associated with blood pressure fluctuations.
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A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patients medication regimen. The patient states that she is eager to beat this disease and looks forward to the time that she will no longer require medication. How should the nurse best respond?
- A. You have a great attitude. This will likely shorten the amount of time that you need medications.
- B. In fact, glaucoma usually requires lifelong treatment with medications.
- C. Most people are treated until their intraocular pressure goes below 50 mm Hg.
- D. You can likely expect a minimum of 6 months of treatment.
Correct Answer: B
Rationale: The correct answer is B: In fact, glaucoma usually requires lifelong treatment with medications.
1. Glaucoma is a chronic condition characterized by increased intraocular pressure.
2. Lifelong treatment is usually necessary to manage intraocular pressure and prevent vision loss.
3. Stopping medication prematurely can lead to worsening of the condition.
4. Therefore, the nurse should educate the patient about the need for ongoing medication to manage glaucoma effectively.
Summary:
A: Incorrect. Having a positive attitude is beneficial, but it does not shorten the duration of glaucoma treatment.
C: Incorrect. The target intraocular pressure is usually below 21 mm Hg, not 50 mm Hg.
D: Incorrect. Glaucoma treatment is typically long-term, not limited to 6 months.
A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
- A. The family is a “pain.”
- B. Pupils equal and reactive to light
- C. Had poor results from the pain medication
- D. Sharp pain of 8 on a scale of 1 to 10
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?
- A. Weight increases.
- B. Weight decreases.
- C. Weight does not change.
- D. Weight fluctuates daily.
Correct Answer: C
Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance.
A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain.
B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss.
D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.
A nurse has provided care to a patient. Whichentry should the nurse document in the patient’s record?
- A. Status unchanged, doing well
- B. Patient seems to be in pain and states, “I feel uncomfortable.”
- C. Left knee incision 1 inch in length without redness, drainage, or edema
- D. Patient is hard to care for and refuses all treatments and medications. Family is present.
Correct Answer: C
Rationale: The correct answer is C because it provides specific, objective information about the patient's left knee incision, including its size and absence of concerning signs. This entry is relevant, concise, and focuses on a specific aspect of the patient's condition, aiding in continuity of care and treatment planning.
Choice A is vague and lacks detail, making it insufficient for accurate patient care documentation. Choice B focuses on the patient's subjective feelings and does not provide objective assessment data. Choice D is judgmental and includes unnecessary information about the patient's behavior and family presence, which is not directly related to the patient's condition.
A 23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what?
- A. Supervised breast self-examination
- B. Mammography
- C. Fine-needle aspiration
- D. Chest x-ray
Correct Answer: B
Rationale: The correct answer is B: Mammography. Mammography is the gold standard for diagnosing breast cancer as it can detect abnormalities such as lumps or tumors in the breast tissue. It provides detailed images that can help healthcare providers identify suspicious areas that may require further testing or biopsy. Supervised breast self-examination (choice A) is important for early detection but is not a diagnostic tool. Fine-needle aspiration (choice C) is a procedure used to obtain a sample of cells for further analysis but is not definitive for diagnosing breast cancer. Chest x-ray (choice D) is used to evaluate the lungs and heart, not the breast tissue for cancer.