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Which patient ismostat risk for increased peristalsis?
- A. A 5-year-old child who ignores the urge to defecate owing to embarrassment
- B. A 21-year-old female with three final examinations on the same day
- C. A 40-year-old female with major depressive disorder
- D. An 80-year-old male in an assisted-living environment
Correct Answer: B
Rationale: The correct answer is B. Stress, like having three final examinations on the same day, can lead to increased peristalsis due to the activation of the sympathetic nervous system. This can result in faster movement of food through the digestive system. The other choices are incorrect because: A - Ignoring the urge to defecate does not directly relate to increased peristalsis. C - Major depressive disorder is more likely to be associated with decreased peristalsis due to the effects of stress on the body. D - Elderly individuals tend to have reduced peristalsis due to age-related changes in the digestive system.
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The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?
- A. Provide small, frequent nutrient-dense meals for maximizing kilocalories.
- B. Prepare hot meals because they are more easily tolerated by the patient.
- C. Avoid salty foods and limit liquids to preserve electrolytes.
- D. Encourage intake of fatty foods to increase caloric intake.
Correct Answer: A
Rationale: The correct answer is A because providing small, frequent nutrient-dense meals helps maximize kilocalories, which is important for patients with AIDS who may have difficulty maintaining weight due to their compromised immune system. This approach ensures the patient receives essential nutrients and energy to support their immune function.
Choice B is incorrect as there is no evidence to suggest that hot meals are more easily tolerated by AIDS patients.
Choice C is incorrect because limiting liquids can lead to dehydration, which is especially detrimental for individuals with weakened immune systems.
Choice D is incorrect as encouraging the intake of fatty foods may not necessarily provide the necessary nutrients and energy required for immune support in AIDS patients.
Which nursing actions will the nurse implementwhen collecting a urine specimen from a patient? (Select all that apply.)
- A. Growing urine cultures for up to 12 hours
- B. Labeling all specimens with date, time, and initials
- C. Allowing the patient adequate time and privacy to void
- D. Wearing gown, gloves, and mask for all specimen handling
Correct Answer: B
Rationale: The correct answer is B: Labeling all specimens with date, time, and initials. This is important for proper identification and tracking of the specimen.
- Choice A is incorrect because urine cultures typically take longer than 12 hours to grow.
- Choice C is incorrect as privacy is important but not a specific action related to urine specimen collection.
- Choice D is incorrect as wearing gown, gloves, and mask may not be necessary for routine urine specimen collection, unless there are specific precautions needed.
A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do?
- A. Call the physician and ask for the order to be confirmed.
- B. Follow the order because this position will help keep the retinal repair intact.
- C. Instruct the patient to maintain this position to prevent bleeding.
- D. Reposition the patient after the first dressing change.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Prone position post retinal detachment repair helps the gas bubble or silicone oil stay against the retina to support healing.
2. This position prevents the bubble/oil from moving and causing further detachment.
3. Repositioning can jeopardize the surgical repair and lead to complications.
4. Calling the physician (A) is unnecessary as the order is clear.
5. Instructing the patient to prevent bleeding (C) is not related to the positioning after retinal detachment repair.
6. Repositioning after the first dressing change (D) contradicts the initial order and risks complications.
A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
- A. Not until the drain is removed
- B. On the second postoperative day
- C. Now, if you wash gently with soap and water
- D. Seven days after your surgery
Correct Answer: A
Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications.
Summary:
B: On the second postoperative day - Too early, the drain needs to be removed first.
C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering.
D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect?
- A. Cytotoxic reaction due to contact with the powder in the gloves
- B. Immune complex reaction due to contact with anesthetic gases
- C. Anaphylaxis due to a latex allergy
- D. Delayed reaction due to exposure to cleaning products
Correct Answer: C
Rationale: The correct answer is C: Anaphylaxis due to a latex allergy. Anaphylaxis is a severe allergic reaction that can be triggered by exposure to latex products such as gloves in the operating room. The symptoms of swelling of the eyes and difficulty breathing are classic signs of anaphylaxis.
Rationale:
1. Swelling of the eyes and difficulty breathing are hallmark symptoms of anaphylaxis.
2. Latex is a common allergen that can cause severe allergic reactions like anaphylaxis.
3. The student's symptoms are occurring shortly after entering the operating room, suggesting an acute allergic reaction.
4. The other choices (A, B, D) do not align with the symptoms presented and are less likely in this scenario.