A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Mnires disease. What question is it most important for the nurse to ask the patient in preparation for this test?

Correct Answer: A

Rationale: The correct answer is A: Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? This question is important because electronystagmography involves the patient being placed in a confined space with sensors attached to monitor eye movements. Claustrophobia or anxiety can significantly impact the patient's ability to tolerate the test, affecting its accuracy. Choice B: Do you currently take any tranquilizers or stimulants on a regular basis? While relevant in some cases, it is not as crucial as ensuring the patient can tolerate the test environment. Choice C: Do you have a history of falls or problems with loss of balance? While relevant to Mnire's disease, it is not directly related to the preparation for electronystagmography. Choice D: Do you have a history of either high or low blood pressure? While monitoring blood pressure is important for some procedures, it is not a primary concern for electronystagmography.

Correct Answer: C

Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications. Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.

Correct Answer: A

Rationale: The correct answer is A because documentation by nurses in various settings like home health, long-term care, and hospitals impacts reimbursement. Proper documentation ensures services provided are accurately reflected, influencing reimbursement. Choice B is incorrect as it refers to Meaningful Use requirements for EHRs, not reimbursement. Choice C is incorrect as a "near miss" relates to patient safety, not reimbursement. Choice D is incorrect because HIPAA focuses on privacy and security of patient information, not reimbursement.

Correct Answer: B

Rationale: The correct answer is B: Mammography. Mammography is the gold standard for diagnosing breast cancer as it can detect abnormalities such as lumps or tumors in the breast tissue. It provides detailed images that can help healthcare providers identify suspicious areas that may require further testing or biopsy. Supervised breast self-examination (choice A) is important for early detection but is not a diagnostic tool. Fine-needle aspiration (choice C) is a procedure used to obtain a sample of cells for further analysis but is not definitive for diagnosing breast cancer. Chest x-ray (choice D) is used to evaluate the lungs and heart, not the breast tissue for cancer.

Correct Answer: D

Rationale: The correct answer is D: Deficiencies occur when fat intake falls below 10% of daily nutrition. Rationale: 1. Fat is essential for absorption of fat-soluble vitamins (A, D, E, K) and for maintaining healthy cell membranes. 2. Fat provides essential fatty acids (omega-3, omega-6) crucial for brain function and inflammation regulation. 3. Adequate fat intake prevents deficiencies like dry skin, poor wound healing, and hormonal imbalances. 4. A low-fat diet should still include at least 10% of daily nutrition from healthy fats for optimal health. Summary: A: Cholesterol intake is important but not the primary focus for a low-fat diet. B: Fats are significant for health, and extreme low-fat diets can lead to deficiencies. C: While some fats are from external sources, the body needs a minimum amount for proper functioning.

Correct Answer: B

Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty. Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.

Correct Answer: C

Rationale: The correct answer is C: Working. In the working phase, the nurse and patient actively collaborate on achieving goals, such as weight reduction strategies. The nurse assesses, plans, and implements interventions with the patient. During this phase, the focus is on building trust, exploring feelings, and identifying and addressing issues. The other choices are incorrect because in the preinteraction phase (A), there is no direct interaction yet, in the orientation phase (B), the relationship is being established, and in the termination phase (D), the relationship is coming to an end. Thus, the nurse being engaged in weight reduction strategies with the patient indicates that they are in the working phase of the helping relationship.

Correct Answer: B

Rationale: The correct answer is B: Initiate high-flow oxygen therapy. Dyspnea in a patient with lung cancer can be caused by hypoxia due to compromised lung function. High-flow oxygen therapy can help improve oxygenation and alleviate dyspnea. Administering a bolus of normal saline (A) would not directly address the underlying cause of dyspnea. Administering high doses of opioids (C) may lead to respiratory depression and should be used cautiously in patients experiencing dyspnea. Administering bronchodilators and corticosteroids (D) may be appropriate for certain types of dyspnea, but in this case, addressing hypoxia with high-flow oxygen therapy is the most appropriate initial nursing action.

Correct Answer: D

Rationale: The correct answer is D. The plausible conclusion the nurse should draw is that the patient has not achieved the desired learning outcomes. 1. The patient's repeated questions indicate a lack of understanding despite the nurse's teaching efforts. 2. This suggests that the patient has not grasped the information provided. 3. It does not necessarily mean the patient is not listening effectively, noncompliant, or has low intelligence. 4. The focus should be on reassessing the teaching methods and providing additional support to help the patient achieve the desired learning outcomes.