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Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?
- A. To reduce the risk of seizures before and after surgery
- B. To avoid intraoperative complications
- C. To reduce cerebral edema
- D. To prevent postoperative vomiting
Correct Answer: A
Rationale: Step 1: Phenytoin is an anticonvulsant used to prevent seizures.
Step 2: Anticonvulsants are often given before surgery to reduce the risk of seizures during and after the procedure.
Step 3: In the context of intracranial surgery, controlling seizures is crucial to prevent complications like increased intracranial pressure.
Step 4: Therefore, administering phenytoin before surgery helps in reducing the risk of seizures before and after the procedure.
Summary:
- Option B (avoid intraoperative complications) is too broad and doesn't directly relate to the use of phenytoin.
- Option C (reduce cerebral edema) is not the primary indication for phenytoin in this scenario.
- Option D (prevent postoperative vomiting) is not a common reason for administering phenytoin before intracranial surgery.
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A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
- A. To identify a life-threatening problem
- B. To establish a database for medical care
- C. To practice respiratory assessment skills
- D. To facilitate the resident’s ability to breathe
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe.
2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention.
3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue.
4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking.
Summary:
- Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking.
- Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database.
- Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation.
- Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.
Which of the ff nursing interventions would a nurse perform to avoid maceration from irritating drainage or the wound compresses in a client with breast abscess?
- A. Apply zinc oxide to the surrounding skin
- B. Use a binder to hold the dressing in place
- C. Support the arm and the shoulder with pillows
- D. Instruct the client not to shave the axillary hair on the side with abscess
Correct Answer: A
Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration.
Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.
At a public health fair, the nurse teaches a group of women about breast cancer awareness. Possible signs of breast cancer include:
- A. Fever.
- B. Nipple discharge and a breast nodule.
- C. Breast changes during menstruation.
- D. Fever and erythema of the breast.
Correct Answer: B
Rationale: The correct answer is B because nipple discharge and a breast nodule are classic signs of breast cancer. Nipple discharge can be bloody or clear, and a breast nodule is a lump that feels different from the surrounding tissue. Fever (choice A) is not a common sign of breast cancer. Breast changes during menstruation (choice C) are normal hormonal fluctuations. Fever and erythema of the breast (choice D) are more indicative of an infection rather than breast cancer. Therefore, choice B is the most relevant sign of breast cancer among the options provided.
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: The correct answer is D, Arcus senilis. This condition does not cause visual problems in the older adult. Arcus senilis is a grayish-white ring around the cornea, which does not affect vision. Glaucoma, macular degeneration, and cataracts are conditions that can lead to visual impairment in older adults. Glaucoma is characterized by increased pressure in the eye, which can damage the optic nerve and lead to vision loss. Macular degeneration affects the central part of the retina, leading to blurred or distorted vision. Cataracts cause clouding of the lens, resulting in decreased vision. Therefore, Arcus senilis is the correct choice as it does not cause visual problems compared to the other conditions listed.
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
- A. 1, 2, 3, 4
- B. 3, 4, 1, 2
- C. 2, 3, 4, 1
- D. 4, 1, 2, 3
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.