Nokea
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.
- A. Foods
- B. Medications
- C. Insect stings
- D. Autoimmunity E) Environmental pollutants
Correct Answer: A
Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.
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The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
- A. Risk for Infection Related to Skin Sloughing
- B. Risk for Acute Pain Related to Loss of Skin Integrity
- C. Risk for Impaired Skin Integrity Related to Cutaneous Lesions
- D. Risk for Impaired Gas Exchange Related to Airway Obstruction
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function.
A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange.
B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise.
C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.
The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
- A. Maintain the irrigation fluid at a warm temperature.
- B. Instill short, sharp bursts of fluid into the ear canal.
- C. Follow the procedure with insertion of a cerumen curette to extract missed ear wax.
- D. Have the patient stand during the procedure.
Correct Answer: A
Rationale: Correct Answer: A. Maintain the irrigation fluid at a warm temperature.
Rationale:
1. Warm fluid helps prevent vertigo and nausea by minimizing stimulation of the vestibular system.
2. Cold fluid can cause dizziness and nausea due to the temperature effect on the inner ear.
3. Warm fluid promotes patient comfort and relaxation during the procedure.
4. Cold fluid can lead to vasoconstriction, potentially exacerbating ear discomfort.
Summary of other choices:
B. Instilling short, sharp bursts of fluid can be uncomfortable and increase the risk of vertigo and nausea.
C. Following with a curette may not be necessary if the irrigation effectively removes the impacted cerumen.
D. Having the patient stand can increase the risk of falling or losing balance due to potential dizziness from the procedure.
A nurse is providing care to a patient from adifferent culture. Which action by the nurse indicates cultural competence?
- A. Communicates effectively in a multicultural context
- B. Functions effectively in a multicultural context
- C. Visits a foreign country
- D. Speaks a different language
Correct Answer: A
Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.
A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect?
- A. Prolactinoma
- B. Angioma
- C. Glioma
- D. Adrenocorticotropic hormone (ACTH)producing adenoma
Correct Answer: A
Rationale: The correct answer is A: Prolactinoma. Hypogonadism is often associated with decreased testosterone levels, which can be caused by excessive prolactin secretion from a prolactinoma. Prolactin inhibits the secretion of gonadotropin-releasing hormone (GnRH), leading to decreased production of testosterone. Angioma, glioma, and ACTH-producing adenoma are not typically associated with hypogonadism. Angiomas are benign tumors of blood vessels, gliomas are tumors of the brain or spinal cord, and ACTH-producing adenomas are associated with Cushing's disease, not hypogonadism.
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
- A. From the tip of the nose to the earlobe
- B. From the tip of the earlobe to the xiphoid process
- C. From the tip of the earlobe to the nose to the xiphoid process
- D. From the tip of the nose to the earlobe to the xiphoid process
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement.
Summary of Incorrect Choices:
A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach.
B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage.
D: Measuring from the tip of the nose to the earlobe to