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The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?
- A. Knowledge deficit regarding impending surgery.
- B. Ineffective management of treatment regimen.
- C. Activity intolerance related to postoperative pain.
- D. Noncompliance with prescribed exercise plan.
Correct Answer: C
Rationale: Step-by-step rationale for choice C:
1. Activity intolerance is a priority nursing problem postoperatively due to pain.
2. Postoperative pain can limit the client's ability to perform activities.
3. Addressing activity intolerance is crucial for promoting recovery and preventing complications.
4. Delaying the teaching session helps the nurse focus on managing pain first.
Summary of why other choices are incorrect:
- Choice A: Knowledge deficit can be addressed after managing immediate postoperative issues.
- Choice B: Treatment regimen management is important but may not be as urgent as addressing activity intolerance related to pain.
- Choice D: Noncompliance with exercise plan can be addressed once the client's pain and activity intolerance are under control.
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When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?
- A. Do you feel safe in your home?
- B. You should not return to your home.
- C. Would you like to see a social worker?
- D. I need to report my concerns to the police.
Correct Answer: A
Rationale: The correct answer is A: "Do you feel safe in your home?" This question is most appropriate because it directly addresses the potential issue of elder abuse without assuming or accusing the patient. It allows the patient to disclose any safety concerns and initiates a conversation about their well-being. Options B and D are inappropriate as they are accusatory and may escalate the situation. Option C is not as direct and may not effectively address the safety concerns of the patient.
Assuming each of these patients was discharged from the hospital, which older adult patient is at greatest risk for decreased functional status and quality of life?
- A. A 70-year-old who had coronary artery bypass surgery developed complications after surgery and had difficulty being weaned from meacbhirba.ncoicma/tle svt entilation. The patient required a tracheostomy and gastrostomy and is now being discharged to a long-term, acute care hospital. The patient lost their sig nificant other 3 years ago.
- B. A 79-year-old admitted for exacerbation of heart failure manages health care independently but needs diuretic medications adjusted . The patient states being compliant with prescribed medications but sometimes forgets to take them. The patient and 82-year-old spouse consider themselves to be independent and support each other.
- C. A 90-year-old admitted for a carotid endarterectomy lives in an assisted living facility (ALF) but is cognitively intact and claims to be the “social butterfly” at all of the events at the ALF. The patient is hospitalized for 4 days and discharged to the ALF.
- D. An 84-year-old who had stents placed to treat coronary artery occlusion has diabetes that has been managed, lives alone since losin g significant other 10 years ago, and was driving prior to hospitalization. The patieanbitr bw.caoms /dteisst charged home within 3 days of the procedure.
Correct Answer: A
Rationale: The correct answer is A because this patient had a complex surgery with complications, requiring long-term care and loss of a significant other, which can impact their emotional well-being and support system. This can lead to decreased functional status and quality of life.
Choice B is incorrect as the patient has support from a spouse and manages health care independently, indicating a good support system. Choice C is incorrect as the patient is cognitively intact and social, which suggests a good quality of life. Choice D is incorrect as the patient had a less complex procedure, well-managed diabetes, and was living independently, which indicates a lower risk for decreased functional status and quality of life compared to choice A.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. A nystagmus on the left.
- B. Exophthalmos on the right.
- C. Ptosis on the left eyelid.
- D. Astigmatism on the right.
Correct Answer: C
Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid.
Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.
Family members are in the patient’s room when the patient has a cardiac arrest and the staff starts resuscitation measures. Which action should the nurse take next?
- A. Keep the family in the room and assign a staff member to explain the care given and answer questions.
- B. Ask the family to wait outside the patient’s room with a designated staff member to provide emotional support.
- C. Ask the family members whether they would prefer to remain in the patient’s room or wait outside the room.
- D. Tell the family members that patients are comforted by having family members present during resuscitation efforts.
Correct Answer: C
Rationale: The correct answer is C because it involves patient-centered care and respects the family's preferences. By asking the family members whether they would prefer to remain in the patient's room or wait outside, the nurse acknowledges their needs and allows them to make an informed decision based on their comfort level. This empowers the family members and promotes a supportive environment during a stressful situation.
Choice A is incorrect because it assumes that keeping the family in the room without their input is the best approach, which may not be the case for all families. Choice B is incorrect because asking the family to wait outside without considering their preferences may not be the most supportive action. Choice D is incorrect because it makes a blanket statement about patient comfort without considering individual family dynamics and preferences.
The nurse is assessing the exhaled tidal volume (EV ) in a mechanically ventilated patient. T What is the rationale for this assessment?
- A. Assess for tension pneumothorax.
- B. Assess the level of positive end-expiratory pressure.
- C. Compare the tidal volume delivered with the tidal volu me prescribed.
- D. Determine the patient’s work of breathing.
Correct Answer: D
Rationale: The correct answer is D: Determine the patient’s work of breathing. Assessing the exhaled tidal volume (EV) in a mechanically ventilated patient helps determine how much effort the patient is exerting to breathe. By monitoring the EV, the nurse can evaluate the patient's respiratory status and adjust ventilator settings if needed. It is crucial to ensure that the patient is not working too hard to breathe, as this can lead to respiratory distress.
Incorrect answers:
A: Assess for tension pneumothorax - Tension pneumothorax is typically assessed through other means such as physical examination and chest X-ray.
B: Assess the level of positive end-expiratory pressure - The level of positive end-expiratory pressure is usually set based on the patient's condition and not solely based on the exhaled tidal volume.
C: Compare the tidal volume delivered with the tidal volume prescribed - This comparison is important but does not directly relate to assessing the patient's work of breathing.