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A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. In this scenario, a platelet count of 50,000/mcL indicates thrombocytopenia, which is a key component of HELLP syndrome. Low platelet count can lead to bleeding complications and is a critical indicator of the syndrome.
Choices B, C, and D are incorrect.
B: Liver enzyme levels within normal range do not necessarily indicate the presence of HELLP syndrome, as elevated liver enzymes are a hallmark feature of the syndrome.
C: Being negative for edema is not a reliable indicator of HELLP syndrome, as edema is a common finding in preeclampsia but not specific to HELLP syndrome.
D: No evidence of nausea or vomiting is not a specific sign of HELLP syndrome, as these
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A patient has just been diagnosed with breast cancer and the nurse is performing a patient interview. In assessing this patients ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask this patient?
- A. What is your level of education?
- B. Are you feeling alright these days?
- C. Is there someone you trust to help you make treatment choices?
- D. Are you concerned about receiving this diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Is there someone you trust to help you make treatment choices? This question assesses the patient's support system and ability to make informed decisions, which are crucial in coping with a breast cancer diagnosis. It shows the nurse's consideration for the patient's emotional well-being and involvement in the decision-making process.
Choice A: What is your level of education? This question is not directly related to coping with the diagnosis of breast cancer and may not provide relevant information about the patient's ability to cope.
Choice B: Are you feeling alright these days? While this question shows concern for the patient's well-being, it does not specifically address coping mechanisms or support systems.
Choice D: Are you concerned about receiving this diagnosis? This question focuses on the patient's emotional reaction to the diagnosis but does not directly assess coping strategies or support systems.
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
- A. You know, you are getting older now and we change as we get older.
- B. The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry.
- C. There is a gradual thickening of the lens of the eye and it can limit the eyes ability for accommodation.
- D. The eye gets shorter, back to front, as we age and it changes how we see things.
Correct Answer: C
Rationale: The correct answer is C because it accurately explains the physiological change in the eye that leads to the need for bifocals. As individuals age, there is a gradual thickening of the lens of the eye, which affects the eye's ability to accommodate for near vision. This thickening makes it harder for the eye to focus on close objects, necessitating the use of bifocals to correct this near vision issue.
Choices A, B, and D are incorrect because they do not provide a scientifically accurate explanation for the need for bifocals in older individuals. Option A is dismissive and does not address the specific change in the eye that leads to the need for bifocals. Option B implies aging as a general concept without specifying the relevant change in the eye. Option D incorrectly states that the eye gets shorter as we age, which is not the reason for needing bifocals.
A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?
- A. Applying a protective eye shield at night
- B. Chewing on the affected side to prevent unilateral neglect
- C. Avoiding the use of analgesics whenever possible
- D. Avoiding brushing the teeth
Correct Answer: A
Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications.
Summary of Incorrect Choices:
B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial.
C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms.
D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.
The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurses best response?
- A. Your tumor originated from somewhere outside the CNS.
- B. Your tumor likely started out in one of your glands.
- C. Your tumor originated from cells within your brain itself.
- D. Your tumor is from nerve tissue somewhere in your body.
Correct Answer: C
Rationale: The correct answer is C because primary brain tumors originate from cells within the brain itself. These tumors develop from abnormal growth of brain cells. Choice A is incorrect as primary brain tumors do not come from outside the central nervous system (CNS). Choice B is incorrect as primary brain tumors do not typically start in glands. Choice D is incorrect as primary brain tumors do not arise from nerve tissue elsewhere in the body. In summary, the nurse should explain to the patient that the tumor originated from cells within his brain to provide accurate information about the nature of primary brain tumors.
The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy when it is scheduled at what time?
- A. Immediately after meals
- B. In the morning
- C. Before bedtime
- D. In the early evening
Correct Answer: B
Rationale: The correct answer is B: In the morning. This is because scheduling physical therapy in the morning allows the patient to benefit from increased energy levels and improved muscle strength and function after a night of rest. Morning sessions can also help set a positive tone for the rest of the day.
Choice A: Immediately after meals can lead to discomfort and potential complications like indigestion or reflux.
Choice C: Before bedtime may be too late in the day when fatigue levels are higher and may disrupt sleep patterns.
Choice D: In the early evening may be less effective as fatigue accumulates throughout the day, and the patient may not have the same level of energy and focus as in the morning.