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A patient has cloudy penile discharge. For which additional symptoms of urethritis should the nurse assess?
- A. Throat or rectal infection
- B. Chancres or vesicles on the genitals
- C. Painful and frequent urination
- D. Oliguria and flank pain
Correct Answer: C
Rationale: The correct answer is C: Painful and frequent urination. Cloudy penile discharge is a common symptom of urethritis, which is inflammation of the urethra. Painful and frequent urination are classic symptoms of urethritis due to irritation and inflammation of the urinary tract. Throat or rectal infection (choice A) are not typically associated with urethritis. Chancres or vesicles on the genitals (choice B) are more indicative of sexually transmitted infections like syphilis or herpes. Oliguria and flank pain (choice D) are more suggestive of kidney or urinary tract issues rather than urethritis.
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A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?
- A. Bacterial infection
- B. High-fat diet
- C. Heredity
- D. Autoimmune reaction
Correct Answer: D
Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.
The nurse notes that a client’s wound has not improved despite consistent wound care as outlined in the care plan. What should the nurse do next?
- A. Reassess the wound and client’s condition.
- B. Discontinue the current care plan.
- C. Increase the frequency of wound dressing changes.
- D. Refer the client to a specialist immediately.
Correct Answer: A
Rationale: Step 1: Reassessing the wound and client's condition allows the nurse to identify any factors contributing to the lack of improvement.
Step 2: It helps determine if the current care plan needs modifications or if there are underlying issues affecting healing.
Step 3: This step ensures a comprehensive evaluation before making any changes to the care plan, promoting evidence-based practice.
Step 4: Choosing this option aligns with the nursing process of assessment, which is crucial for making informed decisions in client care.
Summary:
Option A is correct as it emphasizes the importance of reassessment to gather more information and make informed decisions. Discontinuing the care plan (Option B) without assessment can be harmful. Increasing dressing changes (Option C) may not address the underlying issue. Referring immediately (Option D) may be premature without reassessment.
Another girl was bitten by a poisonous snake. All of the following are true except
- A. The victim of a snake bite should be made to exercise the bitten extremity to hasten circulation
- B. The bite of a poisonous snake is distinguished by two fang marks
- C. Immediate severe pain and swelling distinguished the bite of a poisonous snake
- D. The tourniquet should be tight enough to prevent superficial circulation of blood thus stopping absorption of the poison
Correct Answer: A
Rationale: The correct answer is A because exercising the bitten extremity can increase the spread of the venom. Choice B is correct as poisonous snake bites typically leave two fang marks. Choice C is correct as immediate severe pain and swelling are common symptoms of a poisonous snake bite. Choice D is incorrect as a tourniquet should not be used for snake bites as it can lead to complications such as tissue damage and increased risk of infection.
Following the American Cancer Society guidelines, the nurse should recommend that the women:
- A. Perform breast self-examination annually
- B. Have a mammogram annually
- C. Have a normal receptor assay annually
- D. Have a physician conduct a clinical examination every 2 years
Correct Answer: B
Rationale: The correct answer is B: Have a mammogram annually. Mammograms are recommended by the American Cancer Society for breast cancer screening in women as they are effective in detecting early signs of breast cancer. Mammograms have been shown to reduce mortality rates from breast cancer. Annual mammograms are crucial for early detection and treatment.
A: Performing breast self-examination annually is not recommended as a standalone screening method as it has not been shown to significantly reduce mortality rates.
C: Having a normal receptor assay annually is not a standard screening test for breast cancer recommended by the American Cancer Society.
D: Having a physician conduct a clinical examination every 2 years is not as effective as annual mammograms for detecting early signs of breast cancer.
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
- A. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help
- B. Gently raise Mr. Gabatan to a sitting position to see if the pain either
- C. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover him with any material available
- D. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
Correct Answer: C
Rationale: The correct answer is C because in cases of suspected spinal injury, it is crucial to keep the spine immobilized to prevent further damage. Rolling Mr. Gabatan onto his abdomen helps protect his spine by maintaining alignment. Placing a pad under his head provides support and covering him with any material available helps maintain his body temperature. Moving him without proper spinal precautions (options A, B, D) could worsen his condition. Seeking additional help is important, but ensuring spinal immobilization comes first. Sitting him up or moving him onto a flat piece of lumber can exacerbate spinal injuries. Therefore, option C is the most appropriate initial action.