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Which behaviors indicate the student nurse hasa good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Selectall that apply.)
- A. Writes the patient’s room number and date of birth on a paper for school
- B. Prints/copies material from the patient’s health record for a graded care plan
- C. Reviews assigned patient’s record and another unassigned patient’s record
- D. Gives a change-of-shift report to the oncoming nurse about the patient
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
- Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals.
- A: Writing the patient’s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals.
- B: Printing/copying material from the patient’s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization.
- C: Reviewing assigned patient’s record and another unassigned patient’s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.
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A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
- A. Antigens have bound to antibodies and formed inappropriate immune complexes.
- B. The patients body has mistakenly identified a normal constituent of the body as foreign.
- C. Sensitized T cells have caused cell and tissue damage.
- D. Mast cells have released histamines that directly cause cell lysis.
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction.
Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
- A. Risk for Disuse Syndrome Related to Kaposis Sarcoma B)Impaired Skin Integrity Related to Kaposis Sarcoma C)Diarrhea Related to Kaposis Sarcoma
- B. Impaired Swallowing Related to Kaposis Sarcoma
Correct Answer: B
Rationale: The correct answer is B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing.
Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma. Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma. Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.
A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
- A. Maintenance of good perineal hygiene
- B. Prevention of constipation
- C. Increased fluid intake for 2 weeks postpartum
- D. Performance of pelvic muscle exercises Chapter 58: Breast Cancer: Breast cancer – risks factors, Diagnostic tests and management, Self Breast Exam, Perioperative care: Complications, Rehab, Discharge teaching
Correct Answer: D
Rationale: The correct answer is D, performance of pelvic muscle exercises. Pelvic muscle exercises, also known as Kegel exercises, help strengthen the pelvic floor muscles which support the bladder, uterus, and bowel. By strengthening these muscles, the risk of developing cystocele, rectocele, and uterine prolapse postpartum is reduced. It is a proactive approach to prevent these conditions.
Choice A, maintenance of good perineal hygiene, is important for preventing infections but does not specifically address the risk of pelvic organ prolapse. Choice B, prevention of constipation, is also important but does not directly target the muscle weakness that contributes to prolapse. Choice C, increased fluid intake for 2 weeks postpartum, is not as effective in preventing prolapse as pelvic muscle exercises.
In summary, pelvic muscle exercises are the most appropriate recommendation as they directly address strengthening the muscles that support the pelvic organs, reducing the risk of prolapse postpartum.
The organization of a patients care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice?
- A. It is based on the participation of clinicians without a team leader.
- B. It is based on clinicians of varied backgrounds integrating their separate plans of care.
- C. It is based on communication and cooperation between disciplines.
- D. It is based on medical expertise and patient preference with the support of nursing.
Correct Answer: B
Rationale: Interdisciplinary collaboration involves clinicians from different backgrounds integrating their separate plans of care, ensuring a holistic approach to patient care. This fosters a comprehensive understanding of the patient's needs and individualized care. In contrast, multidisciplinary practice involves clinicians working independently without integrating their plans, potentially leading to fragmented care.
Choice A is incorrect as interdisciplinary collaboration does have a team leader to coordinate and facilitate communication among team members.
Choice C is incorrect because while communication and cooperation are essential in interdisciplinary collaboration, the key distinction is the integration of different perspectives and plans of care.
Choice D is incorrect as interdisciplinary collaboration goes beyond just medical expertise and patient preference, involving professionals from various disciplines working together to address all aspects of patient care.
Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is
- A. varied depending on the stage of gestation.
- B. increased throughout pregnancy and the postpartum period.
- C. decreased throughout pregnancy and the postpartum period.
- D. should not change because the fetus produces its own insulin.
Correct Answer: A
Rationale: Rationale:
1. Insulin needs change during pregnancy due to hormonal changes.
2. During the first trimester, insulin needs may decrease.
3. During the second and third trimesters, insulin needs increase.
4. Postpartum, insulin needs return to pre-pregnancy levels.
Therefore, choice A is correct as insulin needs vary based on gestational stage. Choices B, C, and D are incorrect because insulin needs do not uniformly increase or decrease throughout pregnancy or due to fetal insulin production.