Nokea
A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamped it. The patient develops a urinary tract infection. What do the nurse's actions' exemplify ?
- A. Malpractice
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: D
Rationale: The nurse's actions exemplify negligence. Negligence is a failure to provide reasonable care that results in harm to a patient. In this scenario, the nurse failed to unclamp the patient's indwelling urinary catheter as instructed by the healthcare provider. This failure to follow proper procedure led to the patient developing a urinary tract infection, which could have been prevented if the nurse had acted with reasonable care. This action does not meet the criteria for malpractice, assault, or battery as those involve intentional harm or professional misconduct, whereas negligence involves a lack of appropriate care or attention.
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Ms. C(an adolescent admitted for diagnostic evaluation and nutritional support related to anorexia nervosa)'s self-esteem and weight have gradually improved, but she continues to refer to herself as "fatty." She is able to appropriately verbalize an appropriate diet and exercise plan. What is the priority nursing diagnosis?
- A. Imbalanced Nutrition: less than body requires
- B. Risk for situational low self-esteem
- C. Disturbed body image
- D. Ineffective health maintenance
Correct Answer: C
Rationale: Even though Ms. C's self-esteem and weight have improved, her continued negative self-talk and use of derogatory terms like "fatty" indicate a distorted perception of her body image. This distortion needs to be addressed and corrected for her overall long-term psychological well-being. By focusing on addressing the disturbed body image, the nursing team can help Ms. C develop a more positive self-perception and maintain the progress she has made towards recovery from anorexia nervosa. It is important to prioritize interventions that promote a healthier and more realistic body image in order to support her ongoing recovery journey.
During the surgical procedure, the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form. What should the nurse do?
- A. Proceed with the procedure as planned
- B. Document the discrepancy in the patient's chart
- C. Inform the surgeon and anesthesia provider immediately
- D. Request clarification from the patient and family members
Correct Answer: C
Rationale: If the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form, the immediate action should be to inform the surgeon and anesthesia provider. It is crucial to address any discrepancies before proceeding with the surgical procedure to ensure patient safety and prevent any potential errors or complications. The surgical team needs to be made aware of the issue so that they can verify the correct patient information and ensure that all necessary steps are taken to proceed safely. Communication and collaboration among the healthcare team members are essential in such situations to prevent any harm to the patient.
A patient presents with delayed puberty, short stature, and a childlike appearance. Laboratory tests reveal low levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1). Which endocrine disorder is most likely responsible for these symptoms?
- A. Hyperthyroidism
- B. Hypothyroidism
- C. Diabetes mellitus
- D. Growth hormone deficiency
Correct Answer: D
Rationale: The patient mentioned in the scenario presents with delayed puberty, short stature, and a childlike appearance. These symptoms are indicative of growth hormone deficiency (GHD). GHD is a condition where the pituitary gland does not produce enough growth hormone, which is crucial for normal growth and development.
Nurse Gina has also to consider in terms of financial status most of the elderly are
- A. Sufficient
- B. disoriented
- C. Dependent to others financially
- D. Have pension
Correct Answer: C
Rationale: Nurse Gina has to consider that most of the elderly are dependent on others financially. This is an important factor to take into account when planning and providing care for elderly patients. Many elderly individuals rely on financial assistance from family members, government programs, or retirement funds. Understanding the financial status of elderly patients helps nurses like Gina provide adequate care and support to meet their needs effectively. This can involve coordinating with social services or financial assistance programs to ensure that the patients' financial concerns are addressed along with their healthcare needs.
A patient presents with petechiae, purpura, and mucosal bleeding. Laboratory tests reveal thrombocytopenia, elevated serum creatinine, and schistocytes on peripheral blood smear. Which of the following conditions is most likely to cause these findings?
- A. Thrombotic thrombocytopenic purpura (TTP)
- B. Idiopathic thrombocytopenic purpura (ITP)
- C. Hemolytic uremic syndrome (HUS)
- D. Disseminated intravascular coagulation (DIC)
Correct Answer: A
Rationale: Thrombotic thrombocytopenic purpura (TTP) is a rare but serious condition characterized by microangiopathic hemolytic anemia, thrombocytopenia, neurological abnormalities, fever, and renal dysfunction. The classic pentad of symptoms includes fever, neurologic changes, renal impairment, thrombocytopenia, and microangiopathic hemolytic anemia. The presence of petechiae, purpura, and mucosal bleeding along with thrombocytopenia, elevated serum creatinine, and schistocytes on peripheral blood smear are consistent with TTP. In TTP, there is usually a deficiency of ADAMTS13 (a von Willebrand factor-cleaving protease) leading to excessive platelet adhesion, aggregation, and microthrombi formation within small blood vessels. Treatment typically