Nokea
The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications?
- A. Potassium-sparing diuretics
- B. Cholinergics
- C. Antibiotics
- D. Loop diuretics
Correct Answer: B
Rationale: The correct answer is B: Cholinergics. Glaucoma is a condition characterized by increased intraocular pressure due to impaired drainage of aqueous humor. Cholinergics help to constrict the pupil and improve the outflow of aqueous humor, thus reducing intraocular pressure. This medication class is commonly used to manage glaucoma.
A: Potassium-sparing diuretics are not typically used in the treatment of glaucoma. They are mainly used to manage conditions like hypertension and heart failure.
C: Antibiotics are not indicated for the routine management of glaucoma. They are used to treat infections.
D: Loop diuretics are not commonly used in the treatment of glaucoma. They are primarily used to manage conditions like edema and hypertension.
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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 required enzyme supplements.
- C. The patient will likely require a clear liquid diet.
- D. The patient will benefit from a low-protein diet.
Correct Answer: D
Rationale: The correct answer is D - The patient will benefit from a low-protein diet. Patients with Huntington disease often experience difficulty swallowing and may have involuntary movements, leading to weight loss. A low-protein diet can help manage these symptoms and reduce the risk of aspiration pneumonia. This diet can also help control the chorea movements associated with the disease.
Choice A is incorrect as patients with Huntington disease often have reduced appetite due to swallowing difficulties. Choice B is incorrect as enzyme supplements are not typically indicated in the management of Huntington disease. Choice C is incorrect as a clear liquid diet is not suitable for meeting the nutritional needs of a patient with Huntington disease, who may already be at risk for malnutrition.
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?
- A. These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies.
- B. These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer.
- C. Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy.
- D. Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's symptoms, reassures monitoring, and addresses the cause. It validates his experience while offering a proactive approach. Choice B is incorrect as it dismisses the patient's symptoms and can cause distress. Choice C is incorrect because it generalizes the patient's experience and lacks individualized care. Choice D is incorrect as it may give false hope and oversimplifies the situation. A provides the best balance of empathy and information for the patient's well-being.
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
- A. Rinsing the ears with normal saline after swimming
- B. Avoiding loud environmental noises
- C. Instilling antibiotic ointments on a regular basis
- D. Avoiding the use of cotton swabs
Correct Answer: A
Rationale: The correct answer is A: Rinsing the ears with normal saline after swimming. This is because rinsing with normal saline helps to remove excess moisture and debris, preventing bacterial growth that can lead to otitis externa. Avoiding loud noises (B) is important for overall ear health but does not specifically prevent otitis externa. Instilling antibiotic ointments regularly (C) is not recommended as it can disrupt the ear's natural flora. Avoiding cotton swabs (D) is important to prevent injury but does not directly prevent otitis externa.
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
- A. Risk for Infection Related to Skin Sloughing
- B. Risk for Acute Pain Related to Loss of Skin Integrity
- C. Risk for Impaired Skin Integrity Related to Cutaneous Lesions
- D. Risk for Impaired Gas Exchange Related to Airway Obstruction
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function.
A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange.
B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise.
C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.
A hospice nurse is well aware of how difficult it is to deal with others pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?
- A. Inefficiency in the provision of care
- B. Excessive weight gain
- C. Emotional exhaustion
- D. Social withdrawal
Correct Answer: C
Rationale: The correct answer is C: Emotional exhaustion. Dealing with others' pain daily can lead to burnout and emotional exhaustion for the nurse. This can result in decreased empathy and effectiveness in providing care. Healthy practices such as self-care, setting boundaries, and seeking support can help prevent emotional exhaustion.
Choice A: Inefficiency in the provision of care is incorrect because emotional exhaustion may affect the quality of care but does not necessarily lead to inefficiency.
Choice B: Excessive weight gain is incorrect as it is not directly related to the emotional toll of dealing with others' pain.
Choice D: Social withdrawal is incorrect as it is a potential outcome of emotional exhaustion but not the primary concern in this scenario.