Nokea
A nurse is preparing to perform a gastric lavage procedure for a patient with gastrointestinal bleeding. What action should the nurse prioritize to ensure procedural effectiveness?
- A. Administering antacid medication to the patient before the procedure
- B. Using lukewarm water for gastric lavage to avoid thermal injury
- C. Limiting the lavage fluid volume to prevent fluid overload
- D. Positioning the patient in a left lateral decubitus position during lavage
Correct Answer: D
Rationale: The nurse should prioritize positioning the patient in a left lateral decubitus position during gastric lavage to ensure procedural effectiveness. This position helps to promote optimal drainage of fluid and gastric contents. Placing the patient in a left lateral position allows gravity to assist in the passage of fluid and prevents the risk of aspiration. It also helps to minimize the risk of complications such as reflux of lavage fluid into the respiratory tract. Proper positioning is essential in enhancing the success of the gastric lavage procedure and promoting patient safety.
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A patient presents with a palpable, non-tender mass in the right neck, just below the angle of the mandible. Ultrasound imaging demonstrates a well-defined, hypoechoic lesion with cystic components. Which of the following conditions is most likely responsible for this presentation?
- A. Branchial cleft cyst
- B. Thyroglossal duct cyst
- C. Lymphadenopathy
- D. Parotid gland tumor
Correct Answer: A
Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.
The public health nurse must participate in the essential services that are relevant and accessible to the family and the community. These include:
- A. Working in enforcing laws to regulate health and ensure safety.
- B. Diagnosing and investigating health problems of the country.
- C. Informing, educating, and empowering the people about health.
- D. Monitoring health status and completing a community assessment.
Correct Answer: C
Rationale: The public health nurse's participation in the essential services that are relevant and accessible to the family and the community includes informing, educating, and empowering the people about health. This is a critical aspect of the role of a public health nurse as it involves engaging with individuals and communities to provide them with accurate information about health promotion, disease prevention, and access to healthcare services. By informing, educating, and empowering the people about health, public health nurses can help individuals and communities make informed decisions about their health and well-being, leading to improved health outcomes and overall community health.
A patient with a history of sickle cell disease presents with severe abdominal pain, fever, and jaundice. Laboratory tests reveal anemia, reticulocytosis, elevated indirect bilirubin, and presence of Howell-Jolly bodies on peripheral blood smear. Which of the following conditions is most likely to cause these findings?
- A. Acute splenic sequestration crisis
- B. Aplastic crisis
- C. Hemolytic crisis
- D. Vaso-occlusive crisis
Correct Answer: A
Rationale: Acute splenic sequestration crisis is a complication seen in patients with sickle cell disease characterized by the sudden pooling of sickled red blood cells in the spleen, leading to splenic enlargement, severe anemia, and hypovolemic shock. This pooling results in a rapid drop in hemoglobin levels, causing anemia. The spleen's sequestration of large numbers of red blood cells can cause a sudden rise in the number of immature red blood cells (reticulocytes) in the blood (reticulocytosis). The destruction of these trapped red blood cells in the spleen leads to hemolysis, evidenced by elevated indirect bilirubin levels and the presence of Howell-Jolly bodies (nuclear remnants of erythrocytes) on peripheral blood smear. Patients may present with severe abdominal pain, fever, jaundice, and signs of hemodynamic instability, which
A woman in active labor presents with a prolonged latent phase, characterized by irregular and ineffective contractions. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal hypotension
- B. Maternal anxiety
- C. Fetal macrosomia
- D. Maternal fever
Correct Answer: B
Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.
Mr. C is an older patient with a known history of peripheral vascular disease. The nurse places a heating pad directly on the patient's lower leg to relieve muscle spasms. The heating pad causes a burn, the area becomes infected, and the patient eventually must have a skin graft. This is an example of which of the following?
- A. Malpractice
- B. Vicarious liability
- C. Assault
- D. Negligence
Correct Answer: D
Rationale: Negligence refers to the failure to take proper care in doing something. In this scenario, the nurse failed to exercise the standard of care expected in placing a heating pad directly on Mr. C's lower leg, knowing his history of peripheral vascular disease. This failure led to a burn and subsequent infection that required a skin graft for treatment. The actions of the nurse were negligent as they did not meet the expected standard of care, resulting in harm to the patient. This situation does not fit the definition of assault, malpractice, or vicarious liability, making negligence the most appropriate choice.