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The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health circumstances. In establishing this plan of care for the patient, the nurse should include what intervention?
- A. The patient will receive antianxiety medications every 4 hours.
- B. The patients family will be instructed on planning the patients care.
- C. The patient will be encouraged to verbalize concerns related to the disease and its treatment.
- D. The patient will begin intensive therapy with the goal of distraction.
Correct Answer: C
Rationale: The correct answer is C because encouraging the patient to verbalize concerns can help alleviate anxiety by allowing the patient to express emotions and fears. This intervention promotes emotional expression and provides an outlet for the patient to discuss their worries. This can lead to increased understanding and support.
Incorrect answers:
A: Administering antianxiety medications does not address the underlying cause of anxiety and may lead to dependency.
B: Instructing the family on planning care does not directly address the patient's anxiety.
D: Distracting the patient may provide temporary relief but does not address the root cause of anxiety related to lack of control over health circumstances.
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A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patients complaint?
- A. These pains are an expected finding during the first few weeks of recovery.
- B. The patients complaints are suggestive of a postoperative infection.
- C. The patient may have experienced a spontaneous rupture of the tympanic membrane.
- D. The patients surgery may have been unsuccessful.
Correct Answer: A
Rationale: The correct answer is A. Postoperative day 6 following tympanoplasty and mastoidectomy is still within the early phase of recovery, where occasional sharp, shooting pains in the affected ear can be expected due to the healing process. Here's a step-by-step rationale:
1. Timing: It is only day 6 post-surgery, so it is normal to experience some pain as part of the healing process.
2. Nature of pain: Sharp, shooting pains are common post-surgery due to tissue healing and nerve regeneration.
3. Lack of other symptoms: The patient did not report any other concerning symptoms like fever or discharge, which would be more indicative of an infection.
4. Unlikely complications: Spontaneous rupture of the tympanic membrane or unsuccessful surgery would typically present with more severe and consistent symptoms.
Summary:
- B: Unlikely as there are no other signs of infection.
- C: Unlikely as the pain is described as occasional and sharp.
- D:
A patient has presented for her annual mammogram. The patient voices concerns related to exposure to radiation. What should the nurse teach the patient about a mammogram?
- A. It does not use radiation.
- B. Radiation levels are safe as long as mammograms are performed only once per year.
- C. The negative effects of radiation do not accumulate until late in life.
- D. Radiation from a mammogram is equivalent to an hour of sunlight.
Correct Answer: A
Rationale: Step 1: Mammograms use low-dose X-rays to create images of the breast tissue.
Step 2: The radiation exposure in a mammogram is minimal and considered safe.
Step 3: Choice A is correct as it states that mammograms do not use radiation, which is accurate.
Step 4: Other choices are incorrect because B wrongly implies that annual mammograms are safe due to low radiation levels, C is incorrect as radiation effects can accumulate over time, and D is incorrect as the amount of radiation in a mammogram is much lower than an hour of sunlight.
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults?
- A. The effects of brain tumors are often attributed to the cognitive effects of aging.
- B. Brain tumors in older adults do not normally produce focal effects.
- C. Older adults typically have numerous benign brain tumors by the eighth decade of life.
- D. Brain tumors cannot normally be treated in patient over age
Correct Answer: A
Rationale: The correct answer is A because the cognitive effects of aging can mimic symptoms of brain tumors in older adults, leading to misdiagnosis or delayed diagnosis. Aging can also affect the presentation, progression, and treatment outcomes of brain tumors. Option B is incorrect as brain tumors in older adults can indeed produce focal effects. Option C is incorrect as not all older adults have numerous benign brain tumors, and this is not a factor affecting the diagnosis and treatment of brain tumors in this case. Option D is incorrect as age alone does not preclude treatment for brain tumors.
A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement?
- A. Perform active ROM exercises three times daily.
- B. Sleep on a firm mattress.
- C. Apply cool compresses to the back of the neck daily.
- D. Wear the cervical collar for at least 2 hours at a time.
Correct Answer: B
Rationale: The correct answer is B: Sleep on a firm mattress. A firm mattress helps maintain proper spinal alignment, reducing pressure on the cervical spine. This promotes healing and prevents worsening of symptoms.
A: Performing active ROM exercises may exacerbate symptoms and worsen the condition.
C: Applying cool compresses may provide temporary relief but does not address the underlying issue of spinal alignment.
D: Wearing a cervical collar for extended periods can weaken neck muscles and hinder natural healing processes.
In summary, sleeping on a firm mattress is the most appropriate conservative measure as it supports proper spinal alignment.
The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful?
- A. Otoscopy
- B. Audiometry
- C. Balance testing
- D. Culture and sensitivity testing of ear discharge
Correct Answer: B
Rationale: The correct answer is B: Audiometry. Postoperative audiometry is the most appropriate assessment to determine the success of ossiculoplasty, as it evaluates the patient's hearing function and any improvements made by the surgery. Otoscopy (A) is a visual examination of the ear canal and may not provide comprehensive information on hearing. Balance testing (C) assesses equilibrium and is not directly related to the success of ossiculoplasty. Culture and sensitivity testing (D) of ear discharge is used to identify infections and would not directly indicate the success of the surgery.