Nokea
The nurse is providing care to a 35-year-old female patient who complains of low back pain, pain with defecation, pelvic pressure, and premenstrual spotting. The health care provider has prescribed the hormonal therapy Lupron for this condition. What is the goal of this prescription?
- A. To prevent pregnancy at this time to promote healing
- B. To suppress menstruation and further growth of the tissue
- C. To prevent retrograde menstruation outside the uterine cavity
- D. To increase blood flow to decrease the endometrial lining
Correct Answer: B
Rationale: The goal of prescribing Lupron for this patient is to suppress menstruation and further growth of the tissue. Lupron is a hormonal therapy that works by suppressing the production of certain hormones that stimulate the growth of endometrial tissue. In conditions like endometriosis, where the endometrial tissue grows outside the uterus, suppressing menstruation can help alleviate symptoms such as pelvic pain, back pain, and pelvic pressure. By halting the growth of the tissue, Lupron can help manage the symptoms associated with endometriosis and improve the patient's quality of life.
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Which goal is most appropriate for the collaborative problem of wound infection?
- A. The patient will not exhibit further signs of infection.
- B. Maintain the patient’s fluid intake at 1000 mL/8 hour.
- C. The patient will have a temperature of 98.6F within 2 days.
- D. Monitor the patient to detect therapeutic response to antibiotic therapy.
Correct Answer: A
Rationale: The most appropriate goal for the collaborative problem of wound infection is "The patient will not exhibit further signs of infection." This goal directly addresses the issue of controlling and resolving the infection within the wound, leading to the overall improvement in the patient's condition. By ensuring that the patient does not exhibit further signs of infection, healthcare providers can monitor the effectiveness of treatment interventions and prevent any complications that may arise from the infection spreading or worsening. In contrast, options B, C, and D are not directly related to addressing the wound infection itself, making them less appropriate goals for this specific problem.
A nurse is working in the area of labor and birth. Her assignment is to take care of a gravida 1 para 0 woman who presents in early labor at term. Vaginal exam reflects the following: 2 cm, cervix posterior, –1 station, and vertex with membranes intact. The patient asks the nurse if she can break her water so that her labor can go faster. The nurse’s response, based on the ethical principle of nonmaleficence, is which of the following?
- A. Tell the patient that she will have to wait until she has progressed further on the vaginal exam and then she will perform an amniotomy.
- B. Have the patient write down her request and then call the physician for an order to implement the amniotomy.
- C. Instruct the patient that only a physician or certified midwife can perform this procedure.
- D. Give the patient an enema to stimulate labor.
Correct Answer: A
Rationale: The correct response based on the ethical principle of nonmaleficence, which refers to the duty to do no harm, is to tell the patient that she will have to wait until she has progressed further on the vaginal exam and then perform an amniotomy. In this scenario, breaking the patient's water prematurely could introduce risks and potential harm without clear medical necessity. Performing an amniotomy too early could increase the risk of infection or cause umbilical cord prolapse, which can be harmful to both the mother and the baby. Therefore, it is important for the nurse to wait until the patient has progressed further in labor before considering an amniotomy.
Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
- A. Risk for anxiety related to upcoming birth
- B. Risk for imbalanced nutrition related to NPO status
- C. Risk for altered family processes related to new addition to the family
- D. Risk for injury (maternal) related to altered sensations and positional or physical
changes
Correct Answer: D
Rationale: The priority nursing diagnosis for a patient in active labor should focus on ensuring the safety and well-being of the mother and the baby. "Risk for injury (maternal) related to altered sensations and positional or physical changes" is the most crucial diagnosis in this scenario as it directly addresses potential risks and complications that may occur during labor and delivery. This nursing diagnosis includes considerations for the physical changes the mother undergoes during labor, such as altered sensations and positioning, which can increase the risk of injury. By identifying and addressing this risk promptly, the nurse can help prevent potential harm to the mother and ensure a safe delivery process.
The nurse is planning a teaching session for staff on ethical theories. Which situation best reflects the Deontologic theory?
- A. Approving a physician-assisted suicide
- B. Supporting the transplantation of fetal tissue and organs
- C. Using experimental medications for the treatment of AIDS
- D. Initiating resuscitative measures on a 90-year-old patient with terminal cancer
Correct Answer: D
Rationale: Deontologic theory, also known as deontological ethics, focuses on the duty to follow moral rules and obligations regardless of the consequences. In this scenario, initiating resuscitative measures on a 90-year-old patient with terminal cancer reflects a commitment to upholding the duty to provide care and uphold the sanctity of life. Despite the patient's poor prognosis, the nurse is ethically bound to provide care according to established principles and guidelines, emphasizing duty over outcome. This aligns with the Deontologic theory's emphasis on following moral rules and obligations without consideration of the consequences.
Which goal is most appropriate for the collaborative problem of wound infection?
- A. The patient will not exhibit further signs of infection.
- B. Maintain the patient’s fluid intake at 1000 mL/8 hour.
- C. The patient will have a temperature of 98.6F within 2 days.
- D. Monitor the patient to detect therapeutic response to antibiotic therapy.
Correct Answer: A
Rationale: The most appropriate goal for the collaborative problem of wound infection is "The patient will not exhibit further signs of infection." This goal directly addresses the issue of controlling and resolving the infection within the wound, leading to the overall improvement in the patient's condition. By ensuring that the patient does not exhibit further signs of infection, healthcare providers can monitor the effectiveness of treatment interventions and prevent any complications that may arise from the infection spreading or worsening. In contrast, options B, C, and D are not directly related to addressing the wound infection itself, making them less appropriate goals for this specific problem.