Nokea
A nurse is assessing a patient who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what?
- A. Urinary tract infection
- B. Chronic pain
- C. Permanent vascular damage
- D. Future erectile dysfunction
Correct Answer: C
Rationale: The correct answer is C: Permanent vascular damage. Priapism is a prolonged erection that can lead to ischemia and damage to the penile tissue due to impaired blood flow, potentially resulting in permanent vascular damage. Urinary tract infection (A) is unrelated to priapism. Chronic pain (B) may occur but is not the primary concern. Future erectile dysfunction (D) can result from priapism but is not as immediate or severe as permanent vascular damage. Therefore, C is the most critical consequence to address in priapism.
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A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond?
- A. Overuse of these drops could soften your cornea and damage your eye.
- B. You could lose the peripheral vision in your eye if you used these drops too much.
- C. Im sorry, this medication is considered a controlled substance and patients cannot take it home.
- D. I know these drops will make your eye feel better, but I cant let you take them home.
Correct Answer: A
Rationale: The correct answer is A. Overuse of topical anesthetics can soften the cornea and damage the eye. Topical anesthetics numb the eye, masking pain and potentially leading to overuse. This can prevent the patient from recognizing potential issues like infection or further injury. Additionally, prolonged use can interfere with the cornea's ability to heal properly. Choices B, C, and D are incorrect because they do not address the specific risks associated with using topical anesthetics in the eye. Option B focuses on peripheral vision loss, which is not a direct consequence of using topical anesthetics. Choice C mentions controlled substances, which is not relevant to the situation. Option D acknowledges the patient's request but does not educate the patient on the potential harm of overusing topical anesthetics.
A woman aged 48 years comes to the clinic because she has discovered a lump in her breast. After diagnostic testing, the woman receives a diagnosis of breast cancer. The woman asks the nurse when her teenage daughters should begin mammography. What is the nurses best advice?
- A. Age 28
- B. Age 35
- C. Age 38
- D. Age 48
Correct Answer: D
Rationale: The correct answer is D: Age 48. This recommendation aligns with the current guidelines from major health organizations, such as the American Cancer Society, which suggest that women at average risk should start regular mammograms at age 45 to 54. Screening before age 45 may lead to unnecessary procedures due to false positives. Beginning at age 48 allows for early detection without subjecting the daughters to unnecessary testing at a younger age. Choices A, B, and C are incorrect as they suggest starting mammography at younger ages than recommended, which can increase the likelihood of false positives and unnecessary interventions.
A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T- lymphocyte cell count drops below what threshold?
- A. 75 cells/mm3 of blood
- B. 200 cells/mm3 of blood
- C. 325 cells/mm3 of blood
- D. 450 cells/mm3 of blood
Correct Answer: B
Rationale: The correct answer is B (200 cells/mm3 of blood) because a patient with HIV is considered to have AIDS when their CD4+ T-lymphocyte cell count drops below 200 cells/mm3. This threshold signifies a significant decrease in the immune system's ability to fight off infections and indicates progression to AIDS.
Choice A (75 cells/mm3 of blood) is incorrect because this level is extremely low and would indicate severe immunosuppression, likely leading to AIDS much earlier than anticipated.
Choice C (325 cells/mm3 of blood) and D (450 cells/mm3 of blood) are also incorrect as these levels are within the normal range or slightly lower, which would not meet the criteria for a diagnosis of AIDS.
A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse notes significant urine leakage around the suprapubic tube. What is the nurses most appropriate action?
- A. Cleanse the skin surrounding the suprapubic tube.
- B. Inform the urologist of this finding.
- C. Remove the suprapubic tube and apply a wet-to-dry dressing.
- D. Administer antispasmodic drugs as ordered.
Correct Answer: B
Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage.
Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is N R I G B.C M U S N T O based on which of the following?
- A. Hemorrhage is the primary concern.
- B. She will be unable to conceive in the future.
- C. Bed rest and analgesics are the recommended treatment.
- D. A D&C will be performed to remove the products of conception.
Correct Answer: A
Rationale: The correct answer is A because hemorrhage is the primary concern in ectopic pregnancy due to the risk of rupture and severe bleeding. Immediate intervention is crucial to prevent life-threatening complications.
Choice B is incorrect as future fertility may be affected but is not the immediate concern. Choice C is incorrect as bed rest and analgesics are not effective treatments for ectopic pregnancy. Choice D is incorrect as a D&C is not performed in ectopic pregnancy; surgical intervention is required to remove the ectopic pregnancy.