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Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
- A. Do not leave the patient unattended at any time.
- B. Teach the patient not to bend over.
- C. Report sudden onset of acute pain.
- D. Apply sandbags to either side of the head.
Correct Answer: C
Rationale: In the postoperative period for an eye patient, sudden onset of acute pain can be indicative of a complication or an issue that needs immediate attention. Promptly reporting and addressing the pain is essential to prevent any further complications, such as infection, corneal abrasion, or increased intraocular pressure. This intervention takes priority over the other options listed as it involves the patient's immediate safety and well-being. It is crucial to follow postoperative protocols and report any unexpected or severe symptoms to ensure appropriate treatment and prevent any potential harm to the patient's eyesight.
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As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
- A. I know the hallucinations are parts of the disease
- B. I told her she is wrong and I explained to her what is right
- C. I help her do some tasks he cannot do for himself
- D. Ill turn off the TV when we go to another room
Correct Answer: B
Rationale: Option B, "I told her she is wrong and I explained to her what is right," would require the nurse to give further teaching because it indicates a lack of understanding about how to communicate with a person experiencing hallucinations. People with hallucinations may have a distorted sense of reality, and arguing with them or insisting on what is "right" can be counterproductive. The daughter would benefit from additional education on how to effectively communicate and support her father during episodes of hallucinations.
Which is the best position for an 8-year-old who has returned after an appendectomy for a ruptured appendix?
- A. Right side-lying.
- B. Semi-Fowler.
- C. Prone.
- D. Left side-lying.
Correct Answer: A
Rationale: Right side-lying promotes drainage of the peritoneal cavity and enhances comfort after surgery.
A nurse is conducting a class for adolescent girls about pelvic inflammatory disease (PID). Why should the nurse emphasize the importance of preventing pelvic inflammatory disease (PID)?
- A. PID can be sexually transmitted.
- B. PID cannot be treated.
- C. PID can have devastating effects on the reproductive tract.
- D. PID can cause serious defects in future children of affected adolescents.
Correct Answer: C
Rationale: The nurse should emphasize the importance of preventing pelvic inflammatory disease (PID) because it can have devastating effects on the reproductive tract. PID is often caused by untreated sexually transmitted infections (STIs) and can lead to inflammation and scarring of the fallopian tubes, uterus, and surrounding tissues. If left untreated, PID can result in serious complications such as chronic pelvic pain, infertility, and ectopic pregnancy. Therefore, preventing PID through safe sexual practices and seeking prompt treatment for any signs of infection is crucial to protect the reproductive health of adolescent girls.
Although most relapses in children with Wilms tumor occur early (within 2 yr of diagnosis) and have a favorable outcome, about 15% suffer relapse. Relapse includes all the following EXCEPT
- A. low stage (I/II) at diagnosis
- B. no prior radiotherapy
- C. anaplastic histology
- D. more than 12 mo from nephrectomy
Correct Answer: C
Rationale: Anaplastic histology is associated with a poorer prognosis and is not typically associated with favorable relapse outcomes.
A nurse has determined that a newborn's respiratory breathing is within a normal range. How should the nurse document this finding?
- A. Irregular, abdominal, 30 to 60 breaths/min
- B. Regular, abdominal, 25 to 35 breaths/min
- C. Regular, noisy, 35 to 45 breaths/min
- D. Irregular, quiet, 45 to 55 breaths/min
Correct Answer: B
Rationale: A newborn with normal respiratory breathing would typically exhibit regular breathing patterns, with abdominal movements indicating effective diaphragmatic breathing. The normal respiratory rate for a newborn is considered to be 25 to 35 breaths per minute. Therefore, documenting the newborn's respiratory breathing as "Regular, abdominal, 25 to 35 breaths/min" would accurately represent a normal finding.