Nokea
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: Encouraging verbalization helps the patient gain control over anxiety by understanding the disease and treatment. Routine medications or distraction do not address the root cause, and family planning does not empower the patient.
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A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle?
- A. The patient is likely to have an increased appetite.
- B. The patient is likely to require enzyme supplements.
- C. The patient will likely require a clear liquid diet.
- D. The patient will benefit from a low-protein diet.
Correct Answer: A
Rationale: Huntington's disease causes increased appetite due to involuntary movements, requiring high-calorie diets. Enzyme supplements, clear liquids, or low-protein diets are not indicated.
A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patients vomiting is most consistent with a brain tumor?
- A. The patients vomiting is accompanied by epistaxis.
- B. The patients vomiting does not relieve his nausea.
- C. The patients vomiting is unrelated to food intake.
- D. The patients emesis is blood-tinged.
Correct Answer: C
Rationale: Brain tumor-related vomiting is typically unrelated to food intake due to increased ICP. Epistaxis, blood-tinged emesis, or nausea relief are not characteristic.
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
- A. Page the physician and report this sign of infection.
- B. Reinforce the dressing and reassess in 1 to 2 hours.
- C. Reposition the patient to prevent further hemorrhage.
- D. Inform the surgeon of the possibility of a dural leak.
Correct Answer: D
Rationale: Serosanguineous drainage suggests a dural leak, a serious complication requiring surgical notification. It is not a direct sign of infection, and repositioning or reinforcing the dressing delays critical intervention.
The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy when it is scheduled at what time?
- A. Immediately after meals
- B. In the morning
- C. Before bedtime
- D. In the early evening
Correct Answer: B
Rationale: Morning physical therapy maximizes benefit in postpolio syndrome, as fatigue worsens later in the day.
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
- A. Care of the cervical collar
- B. Technique for performing neck ROM exercises
- C. Home assessment of ABGs
- D. Techniques for restoring nerve function
Correct Answer: A
Rationale: Cervical collar care is essential for post-diskectomy recovery to maintain alignment. ROM exercises, ABG assessment, and nerve restoration are not appropriate.