Nokea
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown:
- A. Ileostomy.
- B. Transverse colostomy.
- C. Ileal conduit.
- D. Sigmoid colostomy.
Correct Answer: A
Rationale: Ileostomies produce more caustic effluent, increasing skin irritation risk.
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Which factor may promote anxiety for a client undergoing a surgical procedure?
- A. Decreased mobility
- B. Unfamiliar environment
- C. Unclear expectations
- D. Decreased alertness
Correct Answer: C
Rationale: The correct answer is C because unclear expectations can increase anxiety in clients facing surgery.
A hospitalized Native American patient tells the nurse that later in the day a medicine man from his tribe is coming to perform a healing ceremony to return his world to balance. What should the nurse recognize about this situation?
- A. The patient does not adhere to an organized,formal religion.
- B. The patient’s spiritual needs may be met by traditional rituals.
- C. The patient’s spiritual needs may be met by traditional rituals.
- D. The patient may be putting his health in jeopardy by relying on rituals.
Correct Answer: B
Rationale: Traditional rituals such as those performed by a medicine man can meet the spiritual needs of Native American patients. This approach respects their cultural beliefs without undermining conventional medical treatment.
What strategies could decrease the distress of rotating shifts for nurses (select all that apply)?
- A. Take a brief onsite nap
- B. Use sleep hygiene practices
- C. Sleep just before going to work
- D. Maintain consistent sleep/wake schedules even on days off (if possible)
Correct Answer: A
Rationale: The correct answers are A, B, and D. Brief naps (A), sleep hygiene (B), and consistent schedules (D) improve adaptation to shift work. Sleeping just before work (C) can worsen sleep quality.
What is the purpose and advantage of methadone maintenance therapy?
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: C
Rationale: The correct answer is C because it is the most appropriate response based on physiological and medical principles.
The medical-surgical nurse, who cares for a patient newly diagnosed with cancer, observes the patient becoming angry with the physicians and nursing staff. The best approach to diffuse the emotionally charged discussion is to
- A. allow the patient and family members time to be alone.
- B. arrange time for the patient to speak with another patient with cancer.
- C. direct the discussion and validation of emotion, without false reassurance.
- D. request a consultation from a social worker on the oncology unit.
Correct Answer: C
Rationale: Validating emotions without dismissing them helps the patient process feelings.