Nokea
A 35-year-old pregnant woman comes to the clinic for her monthly appointment. During assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:
- A. Keratosis.
- B. Mitoasma.
- C. Linea nigra.
- D. Linea gravida.
Correct Answer: C
Rationale: The correct answer is C: Linea nigra. This is a common finding during pregnancy due to hormonal changes causing hyperpigmentation on the abdomen. The other choices are incorrect because keratosis refers to a skin condition characterized by rough, scaly patches; melasma is a condition causing dark patches on the skin, often due to hormonal changes; and linea gravida is not a recognized term in dermatology. Therefore, based on the context of the patient being pregnant and presenting with hyperpigmentation on her face, the most likely finding would be Linea nigra, a dark line that runs from the navel to the pubic bone during pregnancy.
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A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
- A. Administering antibiotics as prescribed.
- B. Encouraging deep breathing and coughing exercises.
- C. Providing pain relief for chest discomfort.
- D. Monitoring oxygen saturation levels.
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
A nurse is teaching a patient with asthma about managing an asthma attack. Which of the following statements by the patient indicates proper understanding?
- A. I will use my inhaler every time I feel an asthma attack coming on.
- B. I will wait for the symptoms to subside on their own before using my inhaler.
- C. I will use my inhaler even if I don't feel any symptoms.
- D. I will not use my inhaler if my symptoms are mild.
Correct Answer: A
Rationale: Rationale: Choice A is correct because using the inhaler at the onset of symptoms can help prevent the asthma attack from worsening. This early intervention can be crucial in managing asthma effectively. Waiting for symptoms to subside (Choice B) can be risky as it may delay necessary treatment. Using the inhaler preventively (Choice C) without symptoms is unnecessary and can lead to overuse. Not using the inhaler for mild symptoms (Choice D) can allow the condition to escalate. Thus, Choice A is the most appropriate response for managing an asthma attack effectively.
A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to prioritize which of the following?
- A. Limiting sodium intake.
- B. Increasing potassium intake.
- C. Increasing fluid intake.
- D. Consuming more caffeine.
Correct Answer: A
Rationale: The correct answer is A: Limiting sodium intake. This is crucial for a patient with hypertension as excess sodium can lead to increased blood pressure. Sodium intake should be limited to lower the risk of cardiovascular complications.
B: Increasing potassium intake is beneficial, but not as critical as limiting sodium for hypertension management.
C: Increasing fluid intake may or may not be necessary depending on the patient's condition, but it is not as crucial as limiting sodium for hypertension management.
D: Consuming more caffeine can actually elevate blood pressure, so it is not recommended for patients with hypertension.
A female nurse is interviewing a male patient who is close in age to the nurse. During the interview, the patient makes an overtly sexual comment. The nurse's best response would be:
- A. Stop that immediately!
- B. Oh, you are too funny. Let's keep going with the interview.
- C. Do you really think I'd be interested?
- D. It makes me uncomfortable when you talk that way. Please don't.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.
A nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
- A. Shortness of breath and weight gain.
- B. Increased urine output and fatigue.
- C. Dizziness and hypotension.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.