AH Exam III Final

The nurse is caring for a patient with pelvic inflammatory disease. The nurse knows that positioning the patient into supine position with the head of the bed to 30 degrees is known to do what?

To promote drainage of the pelvic cavity

A 49-yr-old patient tells the nurse that she is postmenopausal but has recently had occasional spotting. Which initial response by the nurse is appropriate?

"Are you using prescription hormone replacement therapy?" Rationale In postmenopausal women, a common cause of spotting is hormone replacement therapy. Because breakthrough bleeding may be a sign of problems such as cancer or infection, the nurse would not imply that this is normal. The length of time since the last menstrual period is not relevant to the patient's symptoms. Although endometrial cancer may cause spotting, this information is not appropriate as an initial response.

What should a nurse include when educating a patient with Ménière disease?

"Decrease your sodium intake and take your diuretic medication between attacks. Rationale A low-sodium diet and diuretic medications between attacks will prevent edema, which could cause an attack.

An otologist has recommended the use of a hearing aid for a 74-year-old client who has experienced a progressive loss of hearing acuity in recent years. Which of the following should be included in the nurse's teaching plan?

"Even though hearing aids will help you, they also bring challenges like distorted speech and amplified background noise." Rationale Hearing aids do bring challenges, such as distorted speech and amplified background noise. Although hearing aids are not indicated for all individuals with hearing loss, they are not restricted to those with hearing loss due to excessive noise exposure. Hearing aids do not restore hearing to normal. Medicare does not cover the cost of hearing aids.

While summarizing teaching regarding genital herpes, which patient statement indicates a need for further instruction?

"I am not able to infect a sexual partner unless I have active lesions." Rationale: The majority of herpes simplex virus (HSV) transmission occurs during asymptomatic periods. When active lesions are present, the patient is most likely to infect others. There is no cure for HSV, but antiviral medication is prescribed for current infections or suppression of recurrent infections. Early treatment reduces the duration of ulcers and risk of transmission. HSV-1 has been commonly associated with cold sores or fever blisters. HSV-2 has been more associated with genital disease. However, HSV-1 and HSV-2 can cause oral or genital lesions.

Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

"I need to shop for foods low in sodium and avoid adding salt to food." Rationale Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which statement by the patient indicates that the nurse's teaching about treating vaginal candidiasis was effective?

"I should clean carefully after each urination and bowel movement." Rationale Cleaning of the perineal area will decrease itching caused by contact of the irritated tissues with urine and reduce the chance of further infection of irritated tissues by bacteria in the stool. Sexual intercourse should be avoided for 1 week. Douching will disrupt normal protective mechanisms in the vagina. The cream should be used at night so that it will remain in the vagina for longer periods of time.

Which statement by a 24-yr-old patient indicates that the nurse's teaching about management of primary genital herpes has been effective?

"I will take the acyclovir (Zovirax) every 8 hours for the next week." Rationale The treatment regimen for primary genital herpes infections includes acyclovir 400 mg 3 times daily for 7 to 10 days. The patient is taught to abstain from intercourse until the lesions are gone. (Condoms should be used even when the patient is asymptomatic.) Acyclovir ointment is not effective in treating lesions or reducing pain. Herpes infection is chronic and recurrent.

A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include?

"The prednisone dose should be decreased gradually." Rationale Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects. Osteoporosis occurs when patients take corticosteroids for longer periods. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who is postmenopausal comes to the clinic reporting unexpected vaginal bleeding. What should the nurse tell the patient about diagnosing the cause of this bleeding?

"You will need an endometrial biopsy to determine the cause of bleeding."

Presbycusis

(Also called age-related hearing impairment or ARHI) is a form of sensorineural hearing loss that is related to aging and is the most common form of hearing loss. Presbycusis progressively worsens with age and is usually permanent. The cochlea appears to be the site of pathogenesis, but the precise cause of presbycusis is uncertain

When using the accompanying illustration to teach a patient about breast self-examination, the nurse will include the information that most breast cancers are located in which part of the breast?

1 Rationale The upper outer quadrant is the location of most of the glandular tissue of the breast.

In which order will the nurse prepare NPH 20 units and regular insulin 2 units using the same syringe?

1) Rotate NPH vial 2) Inject 20 units of air into NPH vial 3) Inject 2 units of air into regular insulin vial 4) Withdraw regular insulin 5) Withdraw 20 units of NPH

The nurse is educating a postmenopausal woman who is not receiving hormone replacement therapy (HRT) about calcium supplementation. How many milligrams (mg) per day is the recommended dose?

1,500 mg

A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia?

10:00 AM Rationale The rapid-acting insulins peak in 1-3 hours.

After change-of-shift report, which patient should the nurse assess first?

23 y/o w/ type 1 diabetes who has a blood glucose of 40 mg/dL Rationale Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death.

A 52-yr-old man with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective?

Absence of genital lesions Rationale: Primary genital herpes is a viral disorder caused by the herpes simplex virus. Genital herpes results in painful, vesicular lesions. The lesions rupture, form crusts, and heal in 17 to 21 days. Genital warts are caused by the human papillomavirus. Genital herpes is caused by a viral infection (not bacterial). Syphilis is caused by a bacterial organism and results in a chancre, which is a painless, indurated lesion.

A 26 y/o patient w/ diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin?

Abdomen Rationale Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption.

A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

Administer prescribed subcutaneous DDAVP. Rationale Administration of medications is included in LPN/VN education and scope of practice. Assessments, patient teaching, and titrating fluid infusions are more complex skills and should be done by the RN.

A 24-year-old patient who has undergone breast augmentation earlier in the day will be discharged home in the early evening. What instructions should the nurse provide in order to minimize the patient's risk of complications in the immediate recovery period?

Ask the patient to avoid strenuous exercise during her recovery period. Rationale As with all types of breast surgery, strenuous exercise is contraindicated during the recovery period following breast augmentation. A bra should be worn to prevent dehiscence. Passive range-of-motion exercises should be avoided, and sleeping in a semi-Fowler's position is not necessary

A patient reports that her hearing loss has become more severe over the past 3 months. The clinic nurse makes arrangements for an evaluation for a hearing aid. What health care provider should provide this service?

Audiologist Rationale Audiologists assess patients for hearing aids. The other specialists treat ear, nose, and throat (ENT) disorders.

What information should a nurse stress when teaching a patient with Ménière disease about managing the disorder?

Avoiding the use of alcohol and tobacco Rationale The use of alcohol and tobacco products affects the amount of fluid in the middle ear, worsening the symptoms of Ménière disease. The patient with Ménière disease should drink adequate fluid, use antiemetic medications as needed, and conserve energy during the day.

To monitor for complications in a patient w/ type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)?

BP Serum creatinine Urine for microalbuminuria Monofilament testing of the foot Rationale BP, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible miscrovascular and macrovascular complications of diabetes.

An active 28 y/o male w/ type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy?

BP 146/88 mmHg Rationale To decrease the incidence of macrovascular and microvascular problems in patients w/ diabetes, the goal BP is usually 130/80.

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. What topic should the nurse plan to teach the patient?

Calcium supplements to normalize serum calcium levels Rationale Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.

Cerumen Impaction

Cerumen impaction is the most common and easily corrected of all interferences in the hearing of older people When hearing loss is suspected, or a person with existing hearing loss experiences increasing difficulty, it is important first to check for cerumen impaction as a possible cause. After accurate assessment, if cerumen removal is indicated, it may be removed through irrigation, cerumenolytic products, or manual extraction. Individuals at particular risk of impaction are African Americans, individuals who wear hearing aids, and older men with large amounts of ear canal tragi (hairs in the ear) that tend to become entangled with the cerumen

A 38 y/o patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to

Check glucose level before, during, and after swimming Rationale The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration.

The HCP suspects Somogyi effect in a 50 y/o patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?

Check the blood glucose during the night Rationale If the Somogyi effect is causing the patient's increased morning glucose level, the patient will experience hypoglycemia between 2 and 4 AM.

A 33-yr-old patient has a saline breast implant inserted in the outpatient surgery area. Which instruction will the nurse include in the discharge teaching?

Check wound drains for excessive blood or a foul odor. Rationale The patient should be taught drain care because the drains will be in place for 2 or 3 days after surgery. Normal activities can be resumed after 2 to 3 weeks. A bra that provides good support is typically ordered. Aspirin will decrease coagulation and is typically not given after surgery.

What is the best intervention you should use when communicating with a hearing-impaired adult?

Communicating With Elders Who Have Hearing Impairment • Never assume hearing loss is from age until other causes are ruled out (infection, cerumen buildup). • Inappropriate responses, inattentiveness, and apathy may be symptoms of a hearing loss. • Face the individual, and stand or sit on the same level; do not turn away while speaking. • Gain the individual's attention before beginning to speak. Look directly at the person at eye level before starting to speak. • Determine if hearing is better in one ear than another, and position yourself appropriately. • If hearing aid is used, make sure it is in place and batteries are functioning. • Keep hands away from your mouth and project voice by controlled diaphragmatic breathing. • Avoid conversations in which the speaker's face is in glare or darkness; orient the light on the speaker's face. • Careful articulation and moderate speed of speech are helpful. • Lower your tone of voice and articulate clearly. • Label the chart, note on the intercom button, and inform all caregivers that the patient has a hearing impairment. • Use nonverbal approaches: gestures, demonstrations, visual aids, and written materials. • Pause between sentences or phrases to confirm understanding. • When changing topics, preface the change by stating the topic. • Reduce background noise (e.g., turn off television, close door). • Utilize assistive listening devices such as pocket talker. • Verify that the information being given has been clearly understood. Be aware that the person may agree to everything and appear to understand what you have said even when he or she did not hear you (listener bluffing). • Share resources for the hearing-impaired and refer as appropriate.

When caring for a 58-yr-old patient with persistent menorrhagia, what should the nurse plan to monitor?

Complete blood count (CBC) Rationale Because anemia is a likely complication of menorrhagia, the nurse will need to check the CBC. Estrogen and GNRH levels are checked for patients with other problems, such as infertility. Serial hCG levels are monitored in patients who may be pregnant, which is not likely for this patien

A nurse assessing the results of a Rinne test sees the notation of BC > AC. How should the nurse translate this result?

Conductive hearing loss Rationale When the bone conduction (BC) is greater than the air conduction (AC), the results of the Rinne test will read, BC > AC, which means the patient has a conductive hearing loss. The normal finding for the Rinne test is that AC is greater than BC (AC > BC).

A patient undergoing a Weber test says that the sound is louder in her left ear. What should this result indicate?

Conductive hearing loss in the left ear Rationale With the Weber test, a conductive hearing loss is determined by the sound being heard loudest in the affected ear.

A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result should the nurse expect?

Decreased serum sodium Rationale When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take?

Determine what type of activities the patient enjoys Rationale Because consistency w/ exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program.

An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed

Diazepam (Valium) Rationale Worsening of mental status and myxedema coma can be precipitated using sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 19-yr-old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not sought treatment until now because "the warts are so disgusting." Which nursing diagnosis is consistent with these data?

Disturbed body image related to feelings about the genital warts Rationale The patient's statement that her lesions are disgusting suggests that disturbed body image is the major concern. There is no evidence to indicate ineffective coping or lack of knowledge about mode of transmission. The patient may be experiencing anxiety, but there is nothing in the data indicating that the genital warts are impacting interpersonal relationships.

Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus?

Disturbed sleep pattern Rationale Nocturia occurs because of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy?

Do you feel bloated after eating? Rationale Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient.

The nurse is caring for a patient with pelvic inflammatory disease (PID) requiring hospitalization. Which nursing intervention will be included in the plan of care?

Elevate the head of the bed at least 30 degrees. Rationale The head of the bed should be elevated to at least 30 degrees to promote drainage of the pelvic cavity and prevent abscess formation higher in the abdomen. Although a possible complication of PID is acute perihepatitis, liver function test results will remain normal. There is no indication for increased fluid intake. Application of heat is used to reduce pain. Kegel exercises are not helpful in PID. DIF: Cognitive Level: Apply (application) REF: 1252 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

An older nursing home resident reports that her hearing loss is getting worse. What is the first action of the nurse?

Examine the resident's ears for cerumen impaction Rationale When hearing loss is suspected or a person with existing hearing loss experiences increasing difficulty, it is important to first check for cerumen impaction. Hearing aids are not the first intervention since the cause of the hearing loss has not been determined. Hearing aids do not help all type of hearing losses. Raising one's voice is not effective; it often makes hearing more difficult. Lip reading may be a useful skill for an individual with hearing loss, but it is critical to first ascertain what the cause of the hearing loss is.

A 51-yr-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that

FNA is done in the outpatient clinic, and results are available in 1 to 2 days. Rationale FNA is done in outpatient settings, and results are available in 24 to 48 hours. No incision is needed. FNA may be guided by ultrasound but not by mammogram. Because the immobility of the breast lump suggests cancer, further testing will be done if the FNA results are negative.

An elderly patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her?

Face the patient when speaking; demonstrate ideas you wish to convey. Rationale To facilitate communication with a hearing-impaired person, face the patient when speaking, speak slower and in a normal tone, talk toward the patient's best or normal ear, articulate clearly, and demonstrate ideas you wish to convey. You should also position yourself so the light is on your face when you speak.

A patient reports tinnitus and balance problems. The medication that may be responsible is

Furosemide Rationale Ototoxic

A few weeks after an 82 y/o w/ a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss w/ the HCP?

GFR rate is decreased Rationale The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication.

A 30-yr-old woman reports the recent appearance of itchy lesions on her vulva, some of which have recently burst. Which STI should the nurse suspect first?

Genital herpes Rationale: A primary episode of genital herpes is often marked by multiple small, vesicular lesions on the genitals. This symptomatology is not commonly associated with HIV, gonorrhea, or Chlamydia.

The nurse helps the older adult to remove cerumen from the ears. Which of the following interventions should be included in this plan?

Gently irrigate the external auditory canal with warm water. Rationale Cerumen removal can be aided by gentle irrigation of the external auditory canal with warm water or a hydrogen peroxide and water solution. Avoid the use of cotton-tipped applicators for cerumen removal, because they can push the cerumen back into the ear canal and cause an impaction. Hairpins or similar devices should never be used. A forceful stream of solution should not be used during this procedure because it can cause perforation of the eardrum.

The nurse has administered 4oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. 15 minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?

Give the patient 4-6 oz more orange juice Rationale The rule of 15 indicates that administration of quickly acting carbs should be done 2-3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the HCP.

A patient w/ type 2 diabetes is schedules for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?

Glycosylated Hgb level Rationale The A1C test shows the overall control of glucose over 90-120 days.

A patient is considering the use of combined estrogen-progesterone hormone replacement therapy (HRT) during menopause. Which information will the nurse include during their discussion?

HRT decreases osteoporosis risk and increases the risk for cardiovascular disease and breast cancer. Rationale Data from the Women's Health Initiative indicate an increased risk for cardiovascular disease and breast cancer in women taking combination HRT but a decrease in hip fractures. Vaginal creams decrease symptoms related to vaginal atrophy and dryness, but they do not offer the other benefits of HRT, such as decreased hot flashes. Most women who use HRT are placed on short-term treatment and are not treated for up to 10 years. The incidence of colon cancer decreases in women taking HRT.

The nurse is assessing a 22 y/o patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask?

Have you lost weight daily? Rationale Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.

Which common characteristics might a patient with conductive hearing loss display? (Select all that apply.)

Hears adequately in noisy settings Has improved hearing with hearing aids Speaks in a normal volume Rationale Persons with conductive hearing loss can hear in a noisy setting and can have improved hearing with the use of hearing aids. Persons with conductive hearing loss speak at a normal or soft volume because they can hear themselves. Muffled sounds and a history of diabetes would be associated with sensorineural hearing loss.

The patient who has a conductive hearing loss

Hears better in a noisy environment.

A patient with a small breast lump is advised to have a fine needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that

If the specimen is positive for malignancy, the patient can be told at the visit. Rationale An FNA should only be done when an experienced cytologist is available to read the specimen immediately. If the specimen is positive for malignancy, the patient can be given this information immediately. No incision is needed. If the specimen is negative for malignancy, the patient will require biopsy of the lump. FNA is not guided by mammography.

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)?

Increased thyroxine (T4) level Rationale An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the HCP prescribes prednisone. The nurse will anticipate that the patient may

Require administration of insulin while taking prednisone Rationale Glucose levels are increased when patients are taking corticosteroids, and insulin may be required to control blood glucose.

An unresponsive patient w/ type 2 diabetes is brought to the ED and diagnosed w/ hyperosmolar hyperglycemia syndrome (HHS). The nurse will anticipate the need to

Insert a large-bore IV catheter Rationale HHS is initially treated w/ large volumes of IV fluids to correct hypovolemia.

Meniere's Disease

Is a progressive disorder leading to an accumulation of endolymph in the membranous labyrinth. Although it usually affects only one ear, it can affect both. The cause is unknown. Genetic and environmental factors may play a role. The excess fluid and resulting pressure lead to hearing and balance problems, including episodic vertigo, tinnitus, and ear pressure or fullness. Progressive hearing loss occurs over time. The patient has significant disability because of sudden, severe attacks of vertigo with nausea, vomiting, and sweating. A sense of fullness in the ear, increasing tinnitus, and muffled hearing may precede an attack. The patient may have the feeling of being pulled to the ground ("drop attacks"). Some patients report feeling like they are whirling in space. Attacks may last hours or days and may occur several times a year. The clinical course of the disease is highly variable. Results that suggest Ménière's disease include low-frequency sensorineural hearing loss on audiogram, 2 or more spontaneous episodes of vertigo, and abnormal vestibular tests. A glycerol test may aid in diagnosis. The patient receives an oral dose of glycerol, followed by serial audiograms over 3 hours. Improvement in hearing or speech discrimination supports a diagnosis of Ménière's disease. This is attributed to the osmotic effect of glycerol pulling fluid from the inner ear.

Noise-induced hearing loss (NIHL)

Is the second most common cause of sensorineural hearing loss among older adults. Direct mechanical injury to the sensory hair cells of the cochlea causes NIHL, and continuous noise exposure contributes to damage more than intermittent exposure (Lewis, 2014). NIHL is permanent but considered largely preventable. Noise-induced hearing loss may be reduced through the development of better ear-protection devices, education about exposure to loud noise, and emerging research into interventions that may protect or repair hair cells in the ear, which are essential to the body's ability to hear

A 48 y/o male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL. The nurse will plan to teach the patient about

Lifestyle changes to lower blood glucose Rationale The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes.

A significant number of older people have some degree of hearing loss. The nurse is in a key position to educate these individuals about hearing aids. How can the initial period of adjustment to a hearing aid be minimized and the long-term success maximized?

Lower the amplification in noisy environments. Rationale In noisy environments, background noises are amplified, and turning down the volume of the hearing aid can add to comfort. The hearing aid should be worn for short periods at first, and batteries should be replaced earlier than necessary. There is less disturbance from reverberation in the front rows of public meeting places.

A patient has been diagnosed with pelvic inflammatory disease (PID). What is a priority topic that the nurse should discuss with the patient?

Manifestations of further infection

What should the nurse emphasize in the teaching for a woman diagnosed with pelvic inflammatory disease (PID)?

Manifestations of further infection Rationale PID frequently progresses to serious infection of the reproductive structures. The diagnosis does not present a particular need for contraception or specific hygiene measures. HRT is not used to treat PID.

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home?

Provide written reminders of information taught. Rationale Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is complex, teaching should be started well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to

Request that if testing is further delayed, the patient be returned to the unit to eat Rationale Consistency for mealtimes assists w/ regulation of blood glucose, so the best option is for the patient to have lunch at the usual time.

Meniere's Disease Treatment

No cure exists for Ménière's disease. Treatments aim to reduce the number and severity of vertigo attacks. During an acute attack, corticosteroids, antihistamines (e.g., diphenhydramine), anticholinergics (e.g., atropine), and benzodiazepines (e.g., lorazepam [Ativan]) can decrease the abnormal sensation and lessen nausea and vomiting.4 Acute vertigo is treated symptomatically with bed rest, sedation, and antiemetics (e.g., prochlorperazine) or antivertigo drugs (e.g., meclizine) for motion sickness. Management between attacks may include diuretics, corticosteroids, a low-sodium diet, and stress reduction. Frequent and incapacitating attacks are indications for surgical intervention. Decompression of the endolymphatic sac and shunting can reduce the pressure on the cochlear hair cells and prevent further damage and hearing loss. If relief is not achieved, a vestibular nerve section (cutting the nerve) may be done. Plan nursing interventions to minimize vertigo and provide patient safety. During an acute attack, keep the patient in a quiet, darkened room in a comfortable position. Teach the patient to avoid sudden head movements and position changes and to close the eyes until vertigo stops. Avoid fluorescent or flickering lights and television as they may worsen symptoms. Make an emesis basin available because vomiting is common. To minimize the risk for falling, keep the side rails up and the bed in a low position when the patient is in bed. Teach the patient to call for help when getting out of bed. Give medications and fluids parenterally. Monitor intake and output. When the attack subsides, help the patient with ambulation because unsteadiness may remain.

Communicating With Patients With Hearing Impairment

Nonverbal Aids • Draw attention with hand movements. • Have speaker's face in good light. • Avoid light behind the speaker. • Maintain eye contact. • Avoid covering mouth or face with hands. • Avoid chewing, eating, smoking while talking. • Remove background noise. • Move close to better ear. Verbal Aids • Speak normally and slowly. Do not shout. • Do not exaggerate facial expressions. • Do not overenunciate. • Use simple sentences. • Rephrase sentence. Use different words. • Write name or difficult words. • Speak in normal voice directly into better ear.

Which lab value reported to the nurse by the UAP indicates the most urgent need for the nurse's assessment of the patient?

Noon blood glucose of 52 mg/dL Rationale The nurse should assess the patient w/ a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carb-containing beverage such as orange juice.

A 22-yr-old patient tells the nurse that she has not had a menstrual period for the past 3 months. Which action is most important for the nurse to take?

Obtain a urine specimen for a pregnancy test. Rationale Pregnancy should always be considered a possible cause of amenorrhea in women of childbearing age. The other actions are also appropriate, but it is important to check for pregnancy in this patient because pregnancy will require rapid implementation of actions to promote normal fetal development such as changes in lifestyle, folic acid intake, and so on.

Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

Offer the patient hard candies to suck on. Rationale Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.

When teaching a group of young women about pelvic inflammatory disease (PID), what information should the nurse include? Select all that apply.

PID is associated with a higher risk of ectopic pregnancy. Causative organisms reach the pelvic organs through blood.

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?

Patient stopped taking the medication 2 days ago. Rationale Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent or treat adrenal insufficiency. The other information will also be reported but does not require rapid treatment.

A 22 year old female patient has come to the clinic for oral contraceptives. The nurse uses the opportunity for patient teaching about BSE. What should the nurse include in patient teaching?

Perform BSE monthly on the day of the first pill in each package Rationale The nurse instructs the pt to use the packageing for the oral contraceptives as a convienient reminder to perform BSE monthly to increase adherence

When teaching a 22-year-old patient about breast self-examination (BSE), the nurse will instruct the patient that

Performing BSE right after the menstrual period will improve comfort. Rationale Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. The evidence is not clear that BSE reduces breast cancer mortality. BSE should be done monthly. Annual mammograms are not routinely scheduled for women under age

A 75-year-old patient reports having difficulty hearing in crowds but can hear just fine at home with his wife. What hearing disorder should the nurse suspect?

Presbycusis Rationale Presbycusis is a conductive hearing loss associated with normal aging and is caused by changes in the cochlea.

Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm?

Propranolol (Inderal) Rationale -Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

Sensorineural hearing loss

Results from damage to any part of the inner ear or the neural pathways to the brain. Sensorineural hearing loss from increased and prolonged environmental noise, such as amplified sound, is occurring in young adults at an increasing rate. Amplified music (e.g., on smartphones) should not exceed 50% of maximum volume. Ear protection should be worn when firing a gun and during other recreational pursuits with high noise levels. Health teaching about avoiding continued exposure to noise levels greater than 70 dB is essential.

A 24-year-old patient with pelvic inflammatory disease (PID) is being treated with oral antibiotics as an outpatient. Which instruction will be included in patient teaching?

Return for a follow-up appointment in 2 to 3 days. Rationale The patient is instructed to return for follow-up in 48 to 72 hours. The patient should abstain from intercourse for 3 weeks. Abdominal pain should subside with effective antibiotic therapy. Corticosteroids may help prevent inflammation and scarring, but NSAIDs will not decrease scarring

A patient with pelvic inflammatory disease (PID) is being treated with oral antibiotics as an outpatient. Which instruction will be included in patient teaching?

Return for a follow-up appointment in 2 to 3 days. Rationale The patient is instructed to return for follow-up in 48 to 72 hours. The patient should abstain from intercourse for 3 weeks. Abdominal pain should subside with effective antibiotic therapy. Corticosteroids may help prevent inflammation and scarring, but NSAIDs will not decrease scarring. DIF: Cognitive Level: Apply (application) REF: 1252 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which nursing diagnosis should take priority in a nursing care plan for a patient with Ménière disease?

Risk for injury, related to falls Rationale The nursing diagnosis that should take priority is that of preventing injury to the patient. A patient with Ménière's disease is prone to falls because of dizziness.

Hearing Impairment

Screening for hearing loss is an essential component of assessment in older adults. Physical examination includes assessing the external ear to determine any evidence of infection and using an otoscope to visualize the inner ear, looking for any possible causes of conductive hearing loss such as cerumen impaction or the presence of foreign objects. Inspect the tympanic membrane (TM) for integrity. Depending on findings, the patient may need to be referred for follow-up by a specialist. If no problems are identified, perform a few basic screening tests. These may include the Rinne and Weber tests to differentiate between conductive and sensorineural hearing loss. Other tests include the whisper and finger rub test. Hearing loss diminishes quality of life and is associated with multiple negative outcomes, including decreased function, increased likelihood of hospitalizations, miscommunication, depression, falls, loss of self-esteem, safety risks, and cognitive decline. Hearing impairment increases feelings of isolation and may cause older adults to become suspicious or distrustful or to display feelings of paranoia. Because older persons with hearing loss may not understand or respond appropriately to conversation, they may be inappropriately diagnosed with dementia. All of these consequences of hearing impairment further increase social isolation and decrease opportunities for meaningful interaction and stimulation.

Classification of Hearing Loss

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18. Which topics will the nurse include when preparing to teach a patient with recurrent genital herpes simplex (select all that apply)?

Sitz baths may be used to relieve discomfort caused by the lesions. Recurrent genital herpes episodes usually are shorter than the first episode. The virus can infect sexual partners even when you do not have symptoms. Rationale Patients are taught that shedding of the virus and infection of sexual partners can occur even in asymptomatic periods, that recurrent episodes resolve more quickly, and that sitz baths can be used to relieve pain caused by the lesions. Antiviral medications decrease the number of outbreaks but do not cure herpes simplex infections. Infected areas may be kept dry if this decreases pain and itching. REF: 1233

The nurse plans care for older adults living with hearing deficits. Which of the following serious threats to the emotional health should be included in the plan of care?

Social isolation brought on by the difficulty in communication. Rationale Social isolation is a great danger for people with hearing deficit, and it is important for their emotional health to continue the effort to communicate with others. The other cited problems are not as significant a threat to emotional health.

The family of a person with a severe hearing loss may find it difficult to deal with that family member. What is the best advice a nurse can teach the family that will help the situation?

Speak in a low-frequency voice, and use sign language. Rationale Persons with hearing loss hear low-frequency tones better than high-frequency tones; sign language is a useful addition for understanding. Shouting seldom helps, though facing the person does. Although family members may be tempted to just give up and talk with each other, ignoring the person with hearing loss, doing so neglects the person's needs. Hearing aids should be purchased only following expert evaluation and diagnosis.

Which strategies would best aid the nurse communicate with a patient who has a hearing loss (select all that apply)?

Speak normally and slowly. Write out names or difficult words. Use simple sentences Avoid distracting environments.

A patient has been diagnosed with primary dysmenorrhea. How will the nurse suggest that the patient manage discomfort?

Take nonsteroidal antiinflammatory drugs (NSAIDs) when her period starts. Rationale NSAIDs should be started as soon as the menstrual period begins and taken at regular intervals during the usual timeframe when pain occurs. Aerobic exercise may help reduce symptoms. Heat therapy, such as warm packs, is recommended for relief of pain. Antidepressant therapy is not a typical treatment for dysmenorrhea

The nurse is preparing to care for an older adult patient who is hearing-impaired. What is the best way to communicate with this patient?

The best way to communicate with a hearing-impaired patient is to sit facing the person with the light on your face and use short, simple sentences. Avoid using the intercom system as it may distort sound. If the person uses a hearing aid, encourage its use and see that it is situated, turned on, and adjusted before beginning speaking. Be certain you have the patient's attention before speaking. Use short, simple sentences. Ask for visual cues that the patient understands. Place yourself on eye level with the person. Do not speak directly into the person's ear as this prevents the person from obtaining visual cues while you are speaking.

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)?

The patient has a serum sodium level of 118 mEq/L. Rationale A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.

A 28 y/o male patient w/ type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?

The patient increases daily exercise when ketones are present in the urine Rationale When the patient is ketotic, exercise may result in an increase in blood glucose level.

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider?

The patient is confused and lethargic. Rationale The patient's confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.

What information is most important for the nurse to report to the HCP before a patient w/ type 2 diabetes is prepare for a coronary angiogram?

The patient took the prescribed metformin (Glucophage) today Rationale To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered.

A 55 y/o female patient w/ type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient?

The patient will reach an A1C level of less than 7% Rationale The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels.

Which finding indicates a need to contact the HCP before the nurse administers metformin (Glucophage)?

The patient's BUN is 52 mg/dL Rationale The BUN indicates possible renal failure, and metformin should not be used in patients w/ renal failure.

Which finding indicates to the nurse that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

Urinary output is increased. Rationale Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.

What nursing action should be implemented when irrigating a patient's ear?

Use a body temperature solution and have the patient hold a basin under the ear while directing the solution toward the top of the canal. Rationale The irrigation is done with warm water using a small-tipped syringe. The flow is directed upward. If the cerumen does not wash out, the procedure can be repeated but with the same water temperature.

Which patient behaviors should alert a nurse to a possible hearing deficit?

Watches the speaker's mouth Gives inappropriate answers to questions Fails to respond when spoken to Turns the good ear to the speaker Rationale Pulling at the ear is not a signal for hearing loss; all of the other options are.

A 47-yr-old patient asks whether she is going into menopause if she has not had a menstrual period for 3 months. Which response by the nurse is appropriate?

What was your menstrual pattern before your periods stopped?" Rationale The initial response by the nurse should be to assess the patient's baseline menstrual pattern. Although many women do enter menopause in the mid-40s, more information about this patient is needed before telling her that it is likely she is menopausal. Although hormone therapy may be prescribed, further assessment of the patient is needed before discussing therapies for menopause. Because the response to menopause is very individual, the nurse should not assume that the patient is experiencing any adverse emotional reactions.

A 56-yr-old patient is concerned about having a moderate amount of vaginal bleeding after 5 years of menopause. The nurse will anticipate teaching the patient about

endometrial biopsy. Rationale A postmenopausal woman with vaginal bleeding should be evaluated for endometrial cancer, and endometrial biopsy is the primary test for endometrial cancer. D&C will be needed only if the biopsy does not provide sufficient information to make a diagnosis. Endometrial ablation and balloon therapy are used to treat menorrhagia, which is unlikely in this patient.

Promoting healthy hearing

• Avoid exposure to excessively loud noises. • Avoid cigarette smoking. • Maintain blood pressure/cholesterol levels within normal limits. • Eat a healthy diet. • Have hearing evaluated if any changes are noticed. • Avoid injury with cotton-tipped applicators and other cleaning materials.