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:
While it's important for the primary healthcare provider to be informed about the CD4+ results, it's not the first action the nurse should take. The priority is to implement appropriate infection control measures to protect the patient, other patients, and healthcare staff.
CD4+ cell count is a crucial indicator of the patient's immune status. A count of 180/mm is significantly low, suggesting a weakened immune system and increased vulnerability to infections. However, informing the provider alone doesn't directly address the immediate need for infection control.
Rationale for Choice B:
Airborne Precautions are specifically used for patients with known or suspected airborne infections, such as tuberculosis, measles, or varicella. These precautions involve the use of negative pressure rooms and N95 respirators.
In this case, the patient's TB skin test was negative, indicating no evidence of active tuberculosis infection. Implementing Airborne Precautions unnecessarily could lead to excessive resource utilization and potential stigmatization of the patient.
Rationale for Choice C:
Droplet Precautions are used for patients with infections that can be spread through large respiratory droplets, such as influenza, pertussis, or meningococcal meningitis. These precautions involve the use of masks and eye protection.
While the patient's symptoms of fever, night sweats, and severe cough could be consistent with a droplet-spread infection, there's no definitive evidence to support this at the present time. Initiating Droplet Precautions without a clear indication could also lead to unnecessary resource use and potential anxiety for the patient.
Rationale for Choice D:
Standard Precautions are the foundation of infection control and should be used for all patients, regardless of their known or suspected infection status. These precautions include hand hygiene, use of personal protective equipment (PPE) when indicated, and safe handling of sharps and bodily fluids.
By implementing Standard Precautions, the nurse can effectively minimize the risk of transmission of pathogens, protecting both the patient and other individuals in the healthcare setting. This is the most appropriate first action to ensure a safe and appropriate level of care.
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