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When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately?
- A. Fatigue
- B. Temperature greater than 98.5F
- C. Sudden cessation of output from the drainage device
- D. Gradual decline in output from the drain
Correct Answer: C
Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.
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A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurses priority response to this event?
- A. Identify the triggers that precipitated the seizure.
- B. Implement precautions to ensure the patients safety.
- C. Teach the patients family about the relationship between brain tumors and seizure activity.
- D. Ensure that the patient is housed in a private room.
Correct Answer: B
Rationale: The correct answer is B: Implement precautions to ensure the patient's safety. When a patient exhibits seizure activity for the first time, the immediate priority is to ensure the patient's safety by implementing precautions such as protecting the patient from injury during the seizure, ensuring a patent airway, and monitoring vital signs. Identifying triggers (Choice A) can be important for long-term management but is not the priority during an acute seizure. Teaching the family about the relationship between brain tumors and seizures (Choice C) can be done later but is not the immediate priority. Ensuring a private room (Choice D) is not the priority when the patient's safety during a seizure is the main concern.
The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy. This surgery is an example of what type of oncologic surgery?
- A. Salvage surgery
- B. Palliative surgery
- C. Prophylactic surgery
- D. Reconstructive surgery
Correct Answer: C
Rationale: The correct answer is C: Prophylactic surgery. Prophylactic surgery involves removing tissue at risk of developing cancer to prevent the occurrence of cancer. In this case, the patient has a family history of breast cancer and has tested positive for a breast tumor marker, indicating a high risk of developing breast cancer. By opting for a bilateral mastectomy, the patient is proactively removing breast tissue to reduce her risk of developing breast cancer.
Salvage surgery (A) is performed to remove cancer that has recurred after initial treatment. Palliative surgery (B) aims to alleviate symptoms and improve quality of life but is not curative. Reconstructive surgery (D) is performed to restore the appearance and function of a body part after cancer treatment but is not the primary purpose in this scenario.
A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patients preoperative teaching?
- A. The procedure is an effective, time-tested treatment for sensory hearing loss.
- B. The patient is likely to experience resolution of conductive hearing loss after the procedure.
- C. Several months of post-procedure rehabilitation will be needed to maximize benefits.
- D. The procedure is experimental, but early indications suggest great therapeutic benefits.
Correct Answer: B
Rationale: The correct answer is B: The patient is likely to experience resolution of conductive hearing loss after the procedure. This information is crucial to include in the preoperative teaching because it directly addresses the patient's expected outcome, providing reassurance and setting appropriate expectations. Stapedectomy with prosthesis insertion is a well-established treatment for otosclerosis-related conductive hearing loss. Choices A, C, and D are incorrect because they either provide misleading information (A, D) or are not directly relevant to the procedure or the patient's immediate postoperative experience (C). It is important to focus on accurate and relevant information to prepare the patient effectively for the upcoming surgery and its expected outcomes.
A nurse wants to reduce data entry errors onthe computer system. Which action should the nurse take?
- A. Use the same password all the time.
- B. Share password with only one other staff member.
- C. Print out and review computer nursing notes at home.
- D. Chart on the computer immediately after care is provided.
Correct Answer: D
Rationale: The correct answer is D because charting on the computer immediately after care is provided reduces the chances of forgetting important details and ensures accuracy. It also allows for real-time documentation, improving patient care. Choice A is incorrect as using the same password all the time poses a security risk. Choice B is incorrect as sharing passwords compromises confidentiality. Choice C is incorrect as printing out and reviewing notes at home does not address data entry errors on the computer system.
A nurse has assessed that a patient is not yet willing to view her mastectomy site. How should the nurse best assist the patient is developing a positive body image?
- A. Ask the woman to describe the current appearance of her breast.
- B. Help the patient to understand that many women have gone through the same unpleasant experience.
- C. Explain to the patient that her body image does not have to depend on her physical appearance.
- D. Provide the patient with encouragement in an empathic and thoughtful manner.
Correct Answer: D
Rationale: Step 1: Providing encouragement is essential to building trust and rapport with the patient, which is crucial in supporting her emotional needs.
Step 2: Empathy helps the patient feel understood and supported, fostering a positive therapeutic relationship.
Step 3: Thoughtful encouragement acknowledges the patient's feelings and validates her experiences, empowering her to gradually accept her body changes.
Step 4: By offering empathic and thoughtful encouragement, the nurse helps the patient develop a positive body image at her own pace.
Choice A focuses on physical appearance, Choice B generalizes experiences, and Choice C overlooks the patient's emotional journey.