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The patient is having lower abdominal surgeryand the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action?
- A. The patient may void uncontrollably during the procedure.
- B. Local trauma sometimes promotes excessive urine incontinence.
- C. Anesthetics can decrease bladder contractility and cause urinary retention.
- D. The patient will not interrupt the procedure by asking to go to the bathroom.
Correct Answer: C
Rationale: The correct answer is C because anesthetics used during surgery can decrease bladder contractility, leading to urinary retention. By inserting an indwelling catheter, the nurse ensures proper drainage of urine and prevents bladder distention. This helps to maintain the patient's comfort and prevent complications such as urinary retention and potential bladder injury.
Choice A is incorrect because inserting a catheter is not primarily to prevent uncontrollable voiding during surgery. Choice B is incorrect as local trauma does not promote excessive urine incontinence necessitating catheterization. Choice D is incorrect because the primary purpose of catheter insertion is not to prevent interruption of the procedure by bathroom breaks.
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A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?
- A. The patient should not be in contact with the baby after delivery.
- B. The patients treatment poses no risk to his daughter or her infant.
- C. The patients brachytherapy may be contraindicated for safety reasons.
- D. The patient should avoid close contact with his daughter for 2 months.
Correct Answer: B
Rationale: The correct answer is B because brachytherapy does not pose a risk to the patient's daughter or her unborn child. Brachytherapy involves placing radioactive sources inside or near the tumor, which does not make the patient radioactive. The radiation does not travel far and does not pose a risk to others. Therefore, the daughter and her infant are safe from any radiation exposure. Choices A, C, and D are incorrect because there is no need for the patient to avoid contact with the baby after delivery, the brachytherapy is not contraindicated for safety reasons, and there is no requirement for the patient to avoid close contact with his daughter for 2 months.
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment?
- A. Is she able to tell her family of negative test results?
- B. Does she have a sense of peace of mind and a purpose to her life?
- C. Can she let go of her husband so he can make a new life?
- D. Does she need time and space to bargain with God for a cure?
Correct Answer: B
Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty.
Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.
A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care?
- A. The increase in cultural diversity in the United States
- B. Staffing shortages in health care and questions concerning quality of care
- C. Increased costs of health care coupled with inequalities in access
- D. Ability of technology to prolong life beyond meaningful quality of life
Correct Answer: D
Rationale: The correct answer is D: Ability of technology to prolong life beyond meaningful quality of life. In palliative care, the focus is on improving the quality of life for patients with serious illnesses. The use of technology to prolong life can sometimes conflict with this goal, leading to ethical dilemmas. Technology may extend life without considering the patient's comfort or dignity, raising questions about the meaningfulness of prolonging life in such situations. This issue is particularly challenging in palliative care as it requires balancing the benefits of technology with the patient's quality of life.
Other choices are incorrect:
A: The increase in cultural diversity in the United States - While cultural diversity can present challenges in palliative care, it is not the most often presented challenging ethical issue.
B: Staffing shortages in health care and questions concerning quality of care - Staffing shortages are important issues in healthcare, but they do not directly relate to the ethical dilemmas specific to palliative care.
C: Increased costs of health care coupled with
Following a recent history of dyspareunia and lower abdominal pain, a patient has received a diagnosis of pelvic inflammatory disease (PID). When providing health education related to self-care, the nurse should address which of the following topics? Select all that apply.
- A. Use of condoms to prevent infecting others
- B. Appropriate use of antibiotics
- C. Taking measures to prevent pregnancy
- D. The need for a Pap smear every 3 months E) The importance of weight loss in preventing symptoms
Correct Answer: A
Rationale: The correct answer is A: Use of condoms to prevent infecting others. This is important because PID is a sexually transmitted infection and using condoms can help prevent transmission to sexual partners. It is crucial to address this topic to ensure the patient understands the importance of safe sex practices.
The other choices are incorrect:
B: Appropriate use of antibiotics - While antibiotics are used to treat PID, this choice does not address self-care education for prevention.
C: Taking measures to prevent pregnancy - While important for overall health, preventing pregnancy is not directly related to self-care for PID.
D: The need for a Pap smear every 3 months - Pap smears are not directly related to PID management or prevention.
E: The importance of weight loss in preventing symptoms - Weight loss is not a direct self-care measure for managing or preventing PID.
A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition?
- A. Chronic confusion
- B. Impaired urinary elimination
- C. Impaired verbal communication
- D. Bowel incontinence
Correct Answer: C
Rationale: The correct answer is C: Impaired verbal communication. In ALS, motor neurons deteriorate leading to muscle weakness and atrophy, including those involved in speech production. This results in impaired verbal communication. Chronic confusion (A) is not a common manifestation of ALS. Impaired urinary elimination (B) and bowel incontinence (D) are not typically associated with ALS, as it primarily affects motor neurons, not autonomic functions.