A patient has fallen several times in the pastweek when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse ismostappropriate in correcting this urinaryproblem?

Correct Answer: A

Rationale: The correct answer is A: Limit fluid and caffeine intake before bed. This recommendation addresses the issue of nocturia (frequent urination at night) by reducing the amount of urine produced before bedtime, therefore decreasing the need to get up during the night. Caffeine is a diuretic, so limiting its intake can also help reduce the frequency of urination. Choices B, C, and D do not directly address the underlying cause of nocturia and falling. Leaving the bathroom light on (choice B) may help with visibility but does not address the urinary problem. Kegel exercises (choice C) focus on pelvic floor muscles, not bladder muscles. Clearing the path to the bathroom (choice D) can prevent falls but does not address the urinary issue.

Correct Answer: A

Rationale: The correct answer is A because taking time off from work to mourn allows the nurse to process their emotions and prevent burnout. This self-care step promotes mental well-being and helps prevent the nurse from being overwhelmed by their grief. Choice B is incorrect as it may prolong the grieving process and create a constant reminder of the loss. Choice C could potentially burden the patient's family with the nurse's grief, making it an inappropriate action. Choice D, attending the memorial service, may be emotionally challenging and may not provide the nurse with the necessary space to cope with their grief effectively.

Correct Answer: D

Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy. 1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer. 2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy. 3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer. 4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal. 5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.

Correct Answer: C

Rationale: The correct answer is C because it acknowledges that many HIV patients use alternative therapies and emphasizes the importance of weighing the benefits and risks. This response shows respect for the patient's autonomy and preferences while also recognizing the need for informed decision-making. Choice A is incorrect because it dismisses complementary therapies outright without considering individual patient needs or preferences. Choice B is incorrect as it suggests avoiding alternative therapies entirely, which may not align with the patient's wishes or experiences. Choice D is incorrect as it presents a false dichotomy between alternative and medical approaches, disregarding the possibility of integrating both types of treatments.

Correct Answer: B

Rationale: The correct answer is B. Palpating the area for a breast mass is the most appropriate assessment in this scenario as dimpling of the breast can be a sign of underlying breast abnormalities such as a mass or tumor. By palpating the area, the nurse can determine if there is a lump or any other irregularity that may require further investigation. Choice A is incorrect because evaluating the patient's milk production is not relevant to the presenting symptom of breast dimpling. Choice C is incorrect as assessing the patient's knowledge of breast cancer does not address the immediate need for a physical assessment of the breast dimpling. Choice D is incorrect because assuming that the dimpling is just an age-related change without further assessment could delay potential diagnosis and treatment of a serious condition.

Correct Answer: C

Rationale: The correct answer is C because it emphasizes cultural competence and respect for the patient's background. By including racial and ethnic practices with food preferences of the patient, the nurse can provide tailored and relevant nutrition education. This approach promotes inclusivity and acknowledges the importance of cultural traditions in dietary habits. Choices A and B are incorrect as they disregard the patient's cultural background and may lead to cultural insensitivity. Choice D is also incorrect as it focuses on comparison rather than understanding and incorporating the patient's unique cultural context. Overall, choice C aligns with patient-centered care and facilitates effective communication and trust between the nurse and the patient.

Correct Answer: D

Rationale: The correct answer is D because being aware of patients' medication regimens allows nurses to identify and monitor ototoxic medications that can cause hearing loss. By collaborating with other professionals, nurses can adjust medications or recommend alternative treatments to prevent or minimize ototoxicity. This proactive approach directly targets the root cause of potential hearing loss. A: Understanding types of hearing loss is important but does not directly prevent ototoxicity. B: Educating about age-related changes in hearing does not address ototoxicity prevention. C: Educating about noise exposure risks is important for overall hearing health but does not specifically prevent ototoxicity.

Correct Answer: A

Rationale: The correct answer is A because spontaneous termination of a pregnancy is considered an abortion if it occurs before 20 weeks gestation. This is based on the medical definition of abortion as the termination of a pregnancy before the fetus is able to survive outside the womb. Choices B, C, and D are incorrect as they do not accurately reflect the criteria for defining abortion. B and D are specific conditions related to the fetus and the presence of infection, while C refers to passing products of conception intact, which can happen in both spontaneous and induced abortions.

Correct Answer: B

Rationale: The correct answer is B: Administration of methotrexate. This is the priority intervention for an intact tubal pregnancy to prevent further growth and potential rupture of the fallopian tube. Methotrexate is a medication used to stop the growth of the pregnancy tissue. Assessment of pain level (A) is important but not the priority as immediate intervention to address the ectopic pregnancy is crucial. Administration of Rh immune globulin (C) is not the priority in this situation, as it is typically given after a miscarriage or abortion to prevent Rh sensitization. Explanation of common side effects (D) is important for patient education, but it is not the immediate priority when dealing with an ectopic pregnancy.