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The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hypercapnia
- D. Hypocapnia
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin.
Incorrect choices:
B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case.
C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described.
D: Hypocapnia - This is low carbon dioxide levels
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The nurse is caring for a patient of Hispanicdescent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take?
- A. Use long sentences when talking.
- B. Look at the patient when talking.
- C. Use breaks in sentences when talking.
- D. Look at only nonverbal behaviors when talking.
Correct Answer: B
Rationale: The correct answer is B: Look at the patient when talking. This is important because maintaining eye contact shows respect, builds trust, and enhances communication with the patient. By looking at the patient, the nurse can also observe nonverbal cues and ensure the patient is engaged in the conversation.
Choice A: Using long sentences can be overwhelming for a patient who may not understand the language, leading to miscommunication.
Choice C: Using breaks in sentences may help the interpreter better convey the message, but looking at the patient is more essential for effective communication.
Choice D: Looking at only nonverbal behaviors neglects the importance of eye contact and direct communication with the patient.
A patient has fallen several times in the pastweek when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse ismostappropriate in correcting this urinaryproblem?
- A. Limit fluid and caffeine intake before bed.
- B. Leave the bathroom light on to illuminate a pathway.
- C. Practice Kegel exercises to strengthen bladder muscles.
- D. Clear the path to the bathroom of all obstacles before bedtime.
Correct Answer: A
Rationale: The correct answer is A: Limit fluid and caffeine intake before bed. This recommendation addresses the issue of nocturia (frequent urination at night) by reducing the amount of urine produced before bedtime, therefore decreasing the need to get up during the night. Caffeine is a diuretic, so limiting its intake can also help reduce the frequency of urination. Choices B, C, and D do not directly address the underlying cause of nocturia and falling. Leaving the bathroom light on (choice B) may help with visibility but does not address the urinary problem. Kegel exercises (choice C) focus on pelvic floor muscles, not bladder muscles. Clearing the path to the bathroom (choice D) can prevent falls but does not address the urinary issue.
A nurse is teaching the staff about informatics.Which information from the staff indicates the nurse needs to follow up?
- A. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.
- B. A nurse needs to know how to find, evaluate, and use information effectively.
- C. If a nurse has computer competency, the nurse is competent in informatics
- D. Nursing informatics is a recognized specialty area of nursing practice.
Correct Answer: C
Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes.
A: This is a correct statement about informatics proficiency.
B: This is also a correct statement about the skills needed for informatics.
D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up.
In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
- A. Modified radical mastectomies are very hard on a patient, both physically and emotionally and they really arent necessary anymore.
- B. According to current guidelines, having a modified radical mastectomy is no longer seen as beneficial.
- C. Modified radical mastectomies have a poor survival rate because of the risk of cancer recurrence.
- D. According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
Correct Answer: D
Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer.
2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy.
3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer.
4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal.
5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.
The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond?
- A. Privately ask the son to allow the patient to make his own health care decisions.
- B. Explain to the patient that he is responsible for his own decisions.
- C. Work with the team to negotiate informed consent.
- D. Avoid divulging information to the eldest son.
Correct Answer: C
Rationale: The correct answer is C: Work with the team to negotiate informed consent. In this scenario, the nurse should prioritize respecting the patient's cultural beliefs while also ensuring the patient's autonomy and right to make decisions about his own healthcare. By working with the healthcare team to negotiate informed consent, the nurse can involve both the patient and his eldest son in the decision-making process, ensuring that the patient's preferences are respected while also upholding ethical principles of patient autonomy and beneficence. This approach promotes collaboration and respect for cultural values while still safeguarding the patient's rights.
Choice A is incorrect because it does not involve the patient in the decision-making process and could undermine his autonomy. Choice B is incorrect as it disregards the patient's cultural beliefs and preferences. Choice D is incorrect as it may violate the patient's right to information and involvement in his own care.