A nurse working on the postoperative floor has four patients who are scheduled to be discharged tomorrow. Which patient has the greatest need for the nurse to consult with other members of the healthcare team regarding post-discharge care?
A young patient who lives alone, but has nearby family and friends.
An older adult who lives alone at home, despite some memory loss.
A married young adult who is the primary caregiver for children.
A middle-aged patient who has undergone knee replacement and requires physical therapy.
The Correct Answer is B
Choice A rationale:
While a young patient who lives alone may need some assistance with post-discharge care, they have nearby family and friends who can likely provide this support. This patient's situation does not present the same level of complexity and risk as the other patients described in the options.
The presence of nearby family and friends can offer practical and emotional support, helping with tasks such as transportation, meal preparation, and medication management. This social support network can play a crucial role in ensuring a smooth transition from the hospital to home.
Additionally, the patient's young age suggests a higher likelihood of physical and cognitive abilities that can facilitate self-care and adherence to discharge instructions.
Choice B rationale:
The older adult who lives alone and has memory loss has the greatest need for the nurse to consult with other members of the healthcare team regarding post-discharge care. This patient's situation presents several significant challenges that necessitate a collaborative approach to ensure safety and well-being:
Memory loss: The patient's memory loss may impair their ability to follow discharge instructions, manage medications, and maintain personal safety. This raises concerns about potential medication errors, missed appointments, and risks of falls or accidents.
Living alone: The patient's lack of immediate support at home further compounds these risks. Without someone to provide reminders, assistance with tasks, or monitoring for changes in health status, the patient's vulnerability increases.
Potential for social isolation: Living alone with memory loss can also lead to social isolation, which can negatively impact mental and physical health.
Choice C rationale:
While a married young adult who is the primary caregiver for children may face challenges in balancing their own recovery with caregiving responsibilities, they have a spouse who can provide support and assistance. This patient's situation does not present the same degree of risk as the older adult with memory loss living alone.
Choice D rationale:
The middle-aged patient who has undergone knee replacement and requires physical therapy will need support and guidance, but their needs are primarily focused on physical rehabilitation and pain management. These needs can often be addressed through standard discharge planning and coordination with physical therapy services.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Contact inhibition is a normal mechanism that regulates cell growth. When normal cells come into contact with each other, they stop growing. This prevents uncontrolled growth and the formation of tumors.
Benign tumor cells do not typically lose contact inhibition. They still respond to contact signals from neighboring cells and stop growing when they come into contact with each other.
However, they may grow in an uncontrolled manner due to other factors, such as mutations in genes that regulate cell growth.
Choice C rationale:
Invasion is a characteristic of malignant (cancerous) tumors, not benign tumors. Malignant tumors have the ability to invade surrounding tissues and spread to other parts of the body.
Benign tumors, on the other hand, are localized and do not invade surrounding tissues. They may grow and compress nearby tissues, but they do not spread.
Choice D rationale:
Anaplasia is a term used to describe the loss of differentiation of cells in a tumor. This means that the cells no longer resemble the normal cells from which they originated.
Anaplasia is a characteristic of malignant tumors, not benign tumors. Benign tumor cells typically retain some of the characteristics of the parent cells.
Correct Answer is D
Explanation
Rationale for Choice A:
Hydroxychloroquine does not typically cause hair loss as a significant side effect. While some anecdotal reports have suggested hair thinning as a possibility, it's not a well-established or common occurrence in clinical studies.
If a patient experiences hair loss while on hydroxychloroquine, it's essential to rule out other potential causes, such as underlying medical conditions, stress, or nutritional deficiencies.
It's also important to note that some individuals may have a personal predisposition to hair loss, and medications can sometimes trigger or exacerbate this issue.
Rationale for Choice B:
Hydroxychloroquine is not known to cause a burst of energy. In fact, some patients may experience fatigue or drowsiness as a side effect.
It's crucial to inform patients about potential side effects to manage expectations and promote adherence to treatment.
If a patient experiences unexpected energy changes while taking hydroxychloroquine, it's essential to report this to their healthcare provider for further evaluation.
Rationale for Choice C:
Hydroxychloroquine is generally recommended to be taken with food or milk to reduce potential gastrointestinal side effects such as nausea and vomiting.
Taking it on an empty stomach could increase the risk of these side effects, which could impact medication adherence and effectiveness.
Rationale for Choice D:
Retinal damage is the most serious adverse effect of hydroxychloroquine. It can lead to irreversible vision loss if not detected and managed early.
Patients taking hydroxychloroquine must undergo regular eye examinations to monitor for any signs of retinal toxicity.
Early detection and prompt discontinuation of the medication can often prevent permanent vision loss.
It's crucial for nurses to educate patients about this potential risk and emphasize the importance of regular eye exams.
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