During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?

Correct Answer: D

Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently. A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management. B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management. C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.

Correct Answer: A

Rationale: The correct answer is A: Acute pain related to tissue manipulation and incision. This is the most likely major nursing diagnosis because post-surgical pain is a common and expected occurrence after breast surgery. The patient is likely to experience pain due to tissue manipulation and incision during the surgery. Addressing acute pain is crucial for the patient's comfort, well-being, and overall recovery. Choice B (Ineffective coping related to surgery) may be a secondary nursing diagnosis, but acute pain takes priority as it directly impacts the patient's immediate comfort and recovery. Choice C (Risk for trauma related to post-surgical injury) is not the most appropriate nursing diagnosis since the patient has already undergone surgery and is not at risk for further injury at this point. Choice D (Chronic sorrow related to change in body image) is not the most immediate concern post-surgery; addressing acute pain is more critical.

Correct Answer: C

Rationale: Rationale for Correct Answer (C - Taper infusion gradually): 1. Tapering the infusion gradually allows for a smooth transition off PN without causing metabolic disturbances. 2. Abruptly stopping PN can lead to hypoglycemia and electrolyte imbalances. 3. Increasing the rate may cause fluid overload or hyperglycemia. 4. Hanging 5% dextrose alone does not provide adequate nutrition and may not meet the patient's needs.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.

Correct Answer: B

Rationale: The correct answer is B: Denial of imminent death on the part of the family or the patient. This is a common cause of patient care dilemmas at the end of life because denial can lead to unrealistic expectations, difficulty in making important decisions, and inadequate planning for end-of-life care. This can result in unnecessary suffering for the patient and added stress for the family. Incorrect choices: A: Poor communication between the family and the care team can contribute to challenges in providing appropriate care but may not be the primary cause of patient care dilemmas at the end of life. C: Limited visitation opportunities for friends and family, while important for psychosocial support, may not directly cause patient care dilemmas. D: Conflict between family members can complicate decision-making processes, but it is not necessarily a primary cause of patient care dilemmas at the end of life.

Correct Answer: B

Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage. A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring. C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads. D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.

Correct Answer: A

Rationale: The correct answer is A: Connect on a social level. In the RESPECT mnemonic, "R" stands for "Rapport," which is crucial in building a therapeutic relationship with the patient. Connecting on a social level helps establish trust, empathy, and understanding between the nurse and the patient. This connection can lead to better communication, collaboration, and ultimately improved patient outcomes. Summary: - Choice B: Helping the patient overcome barriers is important but not specifically related to establishing rapport in the RESPECT mnemonic. - Choice C: Suspending judgment is important for effective communication but does not directly address building rapport. - Choice D: Stressing collaboration is valuable but does not specifically focus on connecting on a social level to build rapport.

Correct Answer: B

Rationale: Step 1: Immunotherapy injections can cause allergic reactions. Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly. Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed. Step 4: This ensures patient safety and reduces the risk of severe reactions. Summary: A: Epinephrine is not typically given before immunotherapy injections. C: Therapeutic response may take longer than 3 months to show. D: Immunotherapy is usually given via subcutaneous route, not intravenous.

Correct Answer: A

Rationale: The correct answer is A: Diabetic retinopathy. This is because diabetic retinopathy is a leading cause of blindness in adults over 40, resulting from diabetes affecting blood vessels in the retina. Trauma (B) is a common cause of visual impairment but not as prevalent as diabetic retinopathy in this age group. Macular degeneration (C) primarily affects older individuals, typically over 50, rather than those over 40. Cytomegalovirus (D) is a cause of blindness in immunocompromised individuals, not specific to the age group mentioned. Glaucoma (E) is a leading cause of blindness worldwide but is more common in older adults and not specifically over 40.