The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?

Correct Answer: C

Rationale: The correct answer is C: Risk for infection related to altered immunologic response. This is the priority nursing diagnosis for a patient preparing for hematopoietic stem cell transplant (HSCT) because the patient's immune system will be severely compromised post-transplant, leading to a high risk of infections. It is crucial to prioritize infection prevention to ensure the patient's safety and well-being. Choice A is incorrect because while fatigue is common in cancer patients, it is not the priority in this case where infection risk is higher. Choice B is incorrect as altered nutrition can be addressed after managing the risk for infection. Choice D is incorrect as body image disturbance is important but not as critical as preventing infections in this highly vulnerable patient population.

Correct Answer: A

Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications. Choices B, C, and D are incorrect: B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient. C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively. D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.

Correct Answer: B

Rationale: The correct answer is B: In the morning. This is because scheduling physical therapy in the morning allows the patient to benefit from increased energy levels and improved muscle strength and function after a night of rest. Morning sessions can also help set a positive tone for the rest of the day. Choice A: Immediately after meals can lead to discomfort and potential complications like indigestion or reflux. Choice C: Before bedtime may be too late in the day when fatigue levels are higher and may disrupt sleep patterns. Choice D: In the early evening may be less effective as fatigue accumulates throughout the day, and the patient may not have the same level of energy and focus as in the morning.

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: A

Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.

Correct Answer: C

Rationale: The correct answer is C: Identifying the offending agent, if possible. This is prioritized in contact dermatitis to prevent further exposure and recurrence. By identifying the specific irritant or allergen, the nurse can guide the patient in avoiding it, leading to effective management. Choices A, B, and D are incorrect because while promoting adequate perfusion, safe use of topical antihistamines, and teaching the use of an EpiPen may be relevant in certain situations, they do not directly address the root cause of contact dermatitis, which is exposure to the offending agent.

Correct Answer: C

Rationale: The correct answer is C: "This must be very difficult for you." This response acknowledges the patient's emotional state and shows empathy without making assumptions or dismissing their feelings. It validates the patient's emotions and opens up the opportunity for further discussion or support. Rationale: 1. A: "I know how you are feeling" assumes the tutor knows the exact emotions of the patient, which can come off as insincere or dismissive. 2. B: "You have lived a long life" does not address the patient's emotional distress or provide comfort in the face of a terminal illness. 3. D: "Life can be so unfair" does not directly address the patient's feelings and may come off as generic or cliché.

Correct Answer: B

Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (C) is 0-18 inches, too close for an initial nursing history. The public zone (D) is 12 feet or more, too distant for a personal conversation.

Correct Answer: B

Rationale: The correct answer is B: Total placenta previa. In this condition, the placenta completely covers the cervix, posing a risk of severe bleeding during vaginal delivery. Cesarean birth is necessary to avoid potential life-threatening complications for both the mother and the baby. Partial abruptio placentae (choice A) involves premature separation of the placenta, but it doesn't always require a cesarean birth. Ectopic pregnancy (choice C) occurs when the fertilized egg implants outside the uterus, typically requiring surgical intervention but not always a cesarean birth. Eclampsia (choice D) is a serious condition characterized by high blood pressure and seizures, but it doesn't always necessitate cesarean birth unless there are other complications that require it.