Nokea
Which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?
- A. Determining cervical dilation and effacement
- B. Monitoring FHR and maternal vital signs
- C. Observing vaginal bleeding or leakage of amniotic fluid
- D. Determining frequency, duration, and intensity of contractions
Correct Answer: A
Rationale: Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage in a patient admitted with suspected placenta previa. It is important to avoid any unnecessary manipulation of the cervix to prevent complications. Assessing cervical dilation and effacement should be avoided until placenta previa is ruled out to prevent harm to the patient.
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A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?
- A. Teach the patient guided imagery.
- B. Give the patient more control of her antiretroviral regimen.
- C. Increase the patients activity level.
- D. Collaborate with the patients physician to obtain an order for hydromorphone.
Correct Answer: A
Rationale: The most appropriate nursing intervention for a patient with AIDS experiencing extreme anxiety is to teach the patient guided imagery. Guided imagery is a relaxation technique that can help the patient reduce anxiety levels, promote a sense of calm, and improve overall well-being. By teaching the patient how to use guided imagery, the nurse empowers the patient to manage her anxiety in a non-pharmacological way. This intervention promotes self-care and allows the patient to have a tool to use independently beyond the hospital setting. Giving the patient more control of her antiretroviral regimen may be beneficial for adherence but does not directly address the anxiety symptoms. Increasing the patient's activity level may be helpful for overall well-being but may not specifically target the extreme anxiety. Collaborating with the patient's physician to obtain an order for hydromorphone, a potent opioid medication, is not appropriate unless it is indicated for severe pain management, not anxiety.
The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)
- A. Keeping the urine collection container on ice when indicated
- B. Withholding all patient medications for the day
- C. Irrigating the sample as needed with sterile solution
- D. Testing the urine sample with a reagent strip by dipping it in the urine
Correct Answer: A
Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.
A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?
- A. Closely monitoring the input and output of the bladder irrigation system
- B. Administering parenteral nutrition and fluids as ordered
- C. Monitoring the patients level of consciousness and skin turgor
- D. Scanning the patients bladder for retention every 2 hours
Correct Answer: A
Rationale: The nurse should prioritize closely monitoring the input and output of the bladder irrigation system to assess for the risk of imbalanced fluid volume in a patient following a transuretheral resection of the prostate. Bladder irrigation is a common postoperative procedure used to prevent blood clots and help with healing. Monitoring the input and output of the bladder irrigation system is crucial in assessing the patient's fluid balance. Changes in the output may indicate bleeding or retention, which can lead to imbalanced fluid volume. By closely monitoring the bladder irrigation system, the nurse can promptly identify any issues and intervene accordingly to prevent further complications. Monitoring the patient's level of consciousness, skin turgor, and scanning for bladder retention are important assessments, but for this specific situation, monitoring the bladder irrigation system is the priority to assess for imbalanced fluid volume.
A 25-year-old patient diagnosed with invasive cervical cancer expresses a desire to have children. What procedure might the physician offer as treatment?
- A. Radical hysterectomy
- B. Radical culposcopy
- C. Radical trabeculectomy
- D. Radical trachelectomy
Correct Answer: D
Rationale: Radical trachelectomy is a surgical procedure that involves the removal of the cervix while preserving the uterus. This procedure is often offered to young women diagnosed with early-stage cervical cancer who wish to preserve their fertility and have children in the future. By removing the cervix and part of the upper vagina, while leaving the uterus intact, radical trachelectomy offers these patients a chance at preserving their ability to conceive and carry a pregnancy to term. It is a fertility-sparing option in the management of cervical cancer, particularly in younger patients like the 25-year-old mentioned in the question.
A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. A nonmobile mass with irregular edges
- C. A mobile mass that is soft and easily delineated
- D. Nonpalpable right axillary lymph nodes
Correct Answer: B
Rationale: A nonmobile mass with irregular edges would most strongly suggest that the patient's lump is cancerous. Breast cancer lumps typically do not move easily and have irregular, poorly defined edges. These characteristics are concerning because they can indicate an invasive and aggressive growth pattern. Additionally, the fact that the lump is painless is another feature that raises suspicion for malignancy. It is important for the patient to undergo further evaluation, possibly including a mammogram, ultrasound, and biopsy, to determine the nature of the lump and provide appropriate treatment.