Nokea
What is the priority intervention for a patient admitted to your unit diagnosed with advanced amyotrophic lateral sclerosis (ALS)?
- A. Develop a method of communication.
- B. Provide six small meals high in protein and assist with feeding.
- C. Do not involve the patient in decisions about his healthcare because he is not in the mental state to respond.
- D. Provide six normal meals high in protein and assist with feeding.
Correct Answer: A
Rationale: Communication becomes critical as ALS progresses and affects motor functions.
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Cognitive changes include memory problems, confusion, and disorientation. These changes:
- A. Occur in 75% of patients over age 65
- B. Are not a normal part of aging
- C. Are due to enhanced cerebral blood flow
- D. Cause senile plaques and neurofibrillary tangles
Correct Answer: B
Rationale: Cognitive decline is not a normal part of aging; it may indicate underlying conditions such as dementia or Alzheimer's disease. Normal aging involves mild forgetfulness but not significant impairment.
To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations?
- A. When the patient is awake
- B. When the patient first arrives in the PACU
- C. When the patient becomes agitated or frightened
- D. When the patient can be aroused and recognizes where he or she is
Correct Answer: B
Rationale: Early orientation helps prevent confusion and agitation as the patient recovers from anesthesia.
A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for
- A. laboratory tests and perioperative medications.
- B. preoperative and postoperative teaching by the nurse.
- C. psychologic support to alleviate fears of pain and discomfort.
- D. preoperative nursing assessment related to possible risks and complications.
Correct Answer: A
Rationale: Ambulatory centers often streamline processes, reducing the need for extensive laboratory tests and perioperative medications.
What evaluation would help Mr. Jones control his chest pain on inspiration?
- A. Evaluate the intensity and quality of his pain
- B. Explain the cause of his pain
- C. Encourage him to lie on his affected side
- D. Reassure him that the pain will subside
Correct Answer: C
Rationale: Lying on the affected side stabilizes the chest wall, reducing pain during inspiration.
A nurse caring for a patient in the intensive care unit (ICU) implements strategies to create an environment conducive to sleep. Which strategy would be most effective?
- A. Turning off the lights in the room during the night
- B. Having the television on at all times for background noise
- C. Silencing the alarms on the bedside monitor and infusion pumps
- D. Administering ordered analgesics around the clock, even if the patient denies pain
Correct Answer: A
Rationale: The correct answer is A. Turning off the lights minimizes disruption to the patient's circadian rhythm. Background noise (B) and silencing alarms (C) may not always be feasible, and unnecessary analgesics (D) could interfere with sleep.