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When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
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A nurse is caring for an 8-year-old patient whois embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?
- A. “Set your alarm clock to wake you every 2 hours, so you can get up to void.”
- B. “Line your bedding with plastic sheets to protect your mattress.”
- C. “Drink your nightly glass of milk earlier in the evening.”
- D. “Empty your bladder completely before going to bed.”
Correct Answer: C
Rationale: The correct answer is C: “Drink your nightly glass of milk earlier in the evening.” By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake.
Explanation for why the other choices are incorrect:
A: “Set your alarm clock to wake you every 2 hours, so you can get up to void.” This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting.
B: “Line your bedding with plastic sheets to protect your mattress.” This intervention focuses on managing the consequences of bedwetting rather than preventing it.
D: “Empty your bladder completely before going to bed.” While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.
The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
- A. Maintain the irrigation fluid at a warm temperature.
- B. Instill short, sharp bursts of fluid into the ear canal.
- C. Follow the procedure with insertion of a cerumen curette to extract missed ear wax.
- D. Have the patient stand during the procedure.
Correct Answer: A
Rationale: Correct Answer: A. Maintain the irrigation fluid at a warm temperature.
Rationale:
1. Warm fluid helps prevent vertigo and nausea by minimizing stimulation of the vestibular system.
2. Cold fluid can cause dizziness and nausea due to the temperature effect on the inner ear.
3. Warm fluid promotes patient comfort and relaxation during the procedure.
4. Cold fluid can lead to vasoconstriction, potentially exacerbating ear discomfort.
Summary of other choices:
B. Instilling short, sharp bursts of fluid can be uncomfortable and increase the risk of vertigo and nausea.
C. Following with a curette may not be necessary if the irrigation effectively removes the impacted cerumen.
D. Having the patient stand can increase the risk of falling or losing balance due to potential dizziness from the procedure.
The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action?
- A. Placing the patient in a prone position
- B. Assisting the patient into a sitting position
- C. Instilling 15 mL of warm normal saline into one of the patients ears
- D. Assessing the patients baseline hearing by performing the whisper test
Correct Answer: B
Rationale: The correct answer is B: Assisting the patient into a sitting position. The Epley maneuver is used to treat benign paroxysmal positional vertigo by repositioning displaced calcium carbonate crystals in the inner ear. This maneuver involves a series of specific head movements. Starting with the patient in a sitting position allows for proper orientation and positioning for subsequent movements to be effective. Placing the patient in a prone position (A) would not facilitate the correct positioning for the maneuver. Instilling warm saline into the ear (C) is not part of the Epley maneuver. Assessing baseline hearing (D) is unrelated to performing the Epley maneuver.
A nurse is using core measures to reduce healthdisparities. Which group should the nurse focus on to cause themost improvement in core measures?
- A. Caucasians
- B. Poor people
- C. Alaska Natives
- D. American Indians
Correct Answer: B
Rationale: The correct answer is B: Poor people. Focusing on poor people is likely to cause the most improvement in core measures because individuals living in poverty often face multiple barriers to accessing healthcare and have higher rates of chronic conditions. By targeting this group, the nurse can address social determinants of health, improve healthcare access, and address disparities in healthcare outcomes. Other choices (A, C, D) are not as impactful as poverty is a significant factor influencing health disparities.
The nurse is reviewing the instructions given to a patient at 24 weeks’ gestation for a glucose challenge test (GCT). The nurse determines that the patient understands the teaching when she makes which statement?
- A. “I have to fast the night before the test.”
- B. “I will drink a sugary solution containing 100 g of glucose.”
- C. “I will have blood drawn at 1 hour after I drink the glucose solution.”
- D. “I should keep track of my baby’s movements between now and the test.”
Correct Answer: C
Rationale: The correct answer is C: “I will have blood drawn at 1 hour after I drink the glucose solution.” This statement demonstrates understanding of the GCT procedure. The glucose challenge test involves drinking a sugary solution, followed by blood drawn 1 hour later to measure blood glucose levels. This timing is crucial for assessing the body's ability to metabolize glucose, which helps in diagnosing gestational diabetes.
Explanation of why the other choices are incorrect:
A: “I have to fast the night before the test.” - This is incorrect as fasting is not required for the GCT.
B: “I will drink a sugary solution containing 100 g of glucose.” - This is incorrect as the GCT typically involves drinking a solution with a standardized amount of glucose, usually 50 g, not 100 g.
D: “I should keep track of my baby’s movements between now and the test.” - This is unrelated to the GCT procedure and does not demonstrate understanding of the