To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) When the patient first arrives in the PACU. This timing is crucial for several reasons. When a patient is recovering from anesthesia, they may be disoriented, confused, or agitated due to the effects of the anesthesia wearing off. Providing orientation explanations upon arrival in the Post-Anesthesia Care Unit (PACU) allows the nurse to establish a baseline understanding for the patient before they become fully awake and potentially agitated. This early orientation helps reduce anxiety, fear, and agitation by preparing the patient for their surroundings and the recovery process. Option A) When the patient is awake may not be the best choice because by that time, the patient might already be feeling disoriented and anxious, which could lead to agitation. Option C) When the patient becomes agitated or frightened is reactive rather than proactive and may not effectively prevent agitation. Option D) When the patient can be aroused and recognizes where he or she is might be too late as the patient could already be in a state of distress before reaching that point. Educationally, this question highlights the importance of proactive nursing interventions in preventing patient agitation and promoting a smooth recovery process. It emphasizes the significance of timely communication and patient-centered care in the post-anesthesia setting, where patients are vulnerable and require support to navigate the transition from sedation to wakefulness.

Correct Answer: D

Rationale: In this question, the correct answer is option D) Indwelling catheter. An indwelling catheter, also known as a Salem Sump or Levin tube, is specifically designed to drain gastric contents. It is inserted through the nose or mouth, down the esophagus, and into the stomach to remove stomach contents, provide decompression, or administer enteral feedings. Option A) T-tube is incorrect as it is typically used for bile drainage after gallbladder surgery, not gastric drainage. Option B) Hemovac is incorrect as it is a closed wound drainage system used to remove blood and other fluids from a surgical site, not gastric contents. Option C) Nasogastric tube is incorrect in this context as it is used for various purposes such as decompression, feeding, or medication administration, but it is not specifically designed to drain gastric contents like an indwelling catheter. Educationally, understanding the purpose and appropriate use of different types of tubes in clinical practice is crucial for nursing students and healthcare professionals. It is essential to differentiate between various tubes to provide safe and effective patient care based on their specific indications and functions. This knowledge helps in preventing complications and ensuring proper treatment interventions for patients requiring tube management.

Correct Answer: C

Rationale: In this scenario, option C, "I don't drink fluids after 4 P.M.," indicates that Mr. K. needs further health teaching regarding measures to relieve or prevent constipation. Proper hydration is essential for maintaining bowel regularity, and limiting fluids in the evening can contribute to constipation. Option A, "I eat whole-wheat bread with my meals," and option B, "I eat fruit three times a day," are both appropriate strategies to prevent constipation as they provide dietary fiber which aids in digestion and bowel movements. Option D, "I don't like to take enemas," is not directly related to preventive measures for constipation. Enemas are typically used as a last resort for severe constipation and are not a primary method for managing bowel regularity. From an educational perspective, this question highlights the importance of holistic patient education during the rehabilitative phase post-cerebrovascular accident. Nurses must ensure that patients receive comprehensive instructions on managing various aspects of their health, including strategies to prevent constipation to promote overall well-being and recovery.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Pilocarpine. Pilocarpine is a parasympathomimetic drug that acts on the muscarinic receptors in the eye, causing constriction of the pupil (miosis). This medication is commonly used to treat conditions like glaucoma by reducing intraocular pressure. Option A) Epinephrine (Adrenalin) is a sympathomimetic drug that acts on alpha and beta adrenergic receptors, causing dilation of the pupil (mydriasis) rather than constriction. Option B) Acetazolamide (Diamox) is a carbonic anhydrase inhibitor used to decrease intraocular pressure in glaucoma but does not directly affect pupil size. Option C) Atropine is an anticholinergic drug that blocks muscarinic receptors, leading to pupil dilation (mydriasis) rather than constriction. Educationally, understanding the pharmacological actions of different drugs on the eye is crucial for nurses to provide safe and effective care to patients with eye conditions. Knowing the specific effects of medications like pilocarpine can help nurses monitor for intended therapeutic outcomes and potential side effects related to pupillary changes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) has difficulty seeing objects that are very close because her lens is less elastic. Presbyopia is a common age-related condition where the lens of the eye loses its elasticity, making it harder to focus on close objects. This is why Mrs. Williams is experiencing difficulty with near vision. Option A is incorrect because presbyopia affects near vision, not distance vision. Option B is incorrect because nearsightedness (myopia) is the opposite of presbyopia. Option C is incorrect as presbyopia is not caused by a curvature in the eye but rather by the loss of lens elasticity. In an educational context, it is crucial for healthcare professionals to understand common age-related conditions like presbyopia to provide appropriate care and advice to patients. By knowing the correct symptoms and characteristics of presbyopia, healthcare providers can offer effective treatment options and help patients manage their vision changes as they age.