Answer to Part 2
ANSWERS:
1. Correct Answer: 4
Rationale:Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps.
Rationale:Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps.
2. Correct Answer: 4
Rationale:If the pain is constant, the best schedule is around the clock, to provide steady analgesia and pain control. The other options may actually require higher dosages to achieve control.
Rationale:If the pain is constant, the best schedule is around the clock, to provide steady analgesia and pain control. The other options may actually require higher dosages to achieve control.
3. Correct Answer: 3
Rationale:Directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next.
4. Correct Answer: 3
Rationale:Assessing the pain is the priority in this acute care setting, because there is a risk of infection or hemorrhage. The other options might be appropriate based on your assessment findings.
Rationale:Assessing the pain is the priority in this acute care setting, because there is a risk of infection or hemorrhage. The other options might be appropriate based on your assessment findings.
5. Correct Answer: 2
Rationale:Explain that insulin is a priority because life-threatening ketoacidosis is already in progress. If she is already aware of the dangers of an elevated blood glucose level, then her refusal suggests ongoing suicidal intent and the provider should be notified so that steps can be taken to override her refusal (potentially a court order). A blood glucose level of over 600 mg/dL is typically a criterion for transfer to intensive care, but making arrangements for transfer does not address the priority issue, which is refusal of therapy. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of possible ongoing suicidal intent.
Rationale:Explain that insulin is a priority because life-threatening ketoacidosis is already in progress. If she is already aware of the dangers of an elevated blood glucose level, then her refusal suggests ongoing suicidal intent and the provider should be notified so that steps can be taken to override her refusal (potentially a court order). A blood glucose level of over 600 mg/dL is typically a criterion for transfer to intensive care, but making arrangements for transfer does not address the priority issue, which is refusal of therapy. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of possible ongoing suicidal intent.
6. Correct Answer: 4
Rationale:The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic the interventions may be delayed or ignored.
Rationale:The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic the interventions may be delayed or ignored.
7. Correct Answer: 1
Rationale:Pancreatic cancer is more common in African-Americans, males, and smokers. Other associated factors include alcohol use, diabetes, obesity, history of pancreatitis, exposure to organic chemicals, consumption of a high-fat diet, and previous abdominal irradiation.
Rationale:Pancreatic cancer is more common in African-Americans, males, and smokers. Other associated factors include alcohol use, diabetes, obesity, history of pancreatitis, exposure to organic chemicals, consumption of a high-fat diet, and previous abdominal irradiation.
8. Correct Answer: 2,3,5,6,7
Rationale:Mouthwash should not include alcohol, because it has a drying action that leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate.
Rationale:Mouthwash should not include alcohol, because it has a drying action that leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate.
9. Correct Answer: 3
Rationale:
Further assess what the patient means by having “control over my own life and death.” This could be an indirect statement of suicidal intent. A patient who believes he will be cured should also be assessed for misunderstanding what the physician said; however, the patient may need to use denial as a temporary defense mechanism. The patient's acknowledgment that the treatments are for control of symptoms or plans: for the immediate future suggest an understanding of what the physician said.
Rationale:
Further assess what the patient means by having “control over my own life and death.” This could be an indirect statement of suicidal intent. A patient who believes he will be cured should also be assessed for misunderstanding what the physician said; however, the patient may need to use denial as a temporary defense mechanism. The patient's acknowledgment that the treatments are for control of symptoms or plans: for the immediate future suggest an understanding of what the physician said.
10. Correct Answer: 3
Rationale:Paresthesia is a side effect associated with some chemotherapy drugs such as vincristine. The physician can modify the dosage or discontinue the drug. Fatigue, nausea, vomiting, and anorexia are common side effects of many chemotherapy medications. The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and encouraging small meals containing high-protein and high-calorie foods.
Rationale:Paresthesia is a side effect associated with some chemotherapy drugs such as vincristine. The physician can modify the dosage or discontinue the drug. Fatigue, nausea, vomiting, and anorexia are common side effects of many chemotherapy medications. The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and encouraging small meals containing high-protein and high-calorie foods.
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