A patient presents with a painful, vesicular rash following a linear pattern on the left forearm. The patient reports a history of gardening without gloves. Which of the following conditions is most likely responsible for this presentation?
- A. Allergic contact dermatitis
- B. Herpes simplex virus infection
- C. Scabies
- D. Poison ivy dermatitis
Correct Answer: B
Rationale: The correct answer is B: Herpes simplex virus infection. The presentation of a painful, vesicular rash following a linear pattern on the left forearm is characteristic of herpes simplex virus infection, specifically herpes zoster (shingles). The linear pattern is due to the virus following a specific nerve pathway. This is different from the other choices - A: Allergic contact dermatitis typically presents as a diffuse rash at the site of contact with an allergen, not a linear pattern. C: Scabies presents with burrows and papules, not vesicles in a linear pattern. D: Poison ivy dermatitis causes a diffuse rash, not a linear vesicular rash.
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A patient in the ICU develops acute exacerbation of chronic obstructive pulmonary disease (COPD) characterized by worsening dyspnea and increased sputum production. What intervention should the healthcare team prioritize to manage the patient's exacerbation?
- A. Administer bronchodilator medications via nebulization for bronchodilation.
- B. Initiate non-invasive positive pressure ventilation (NIPPV) for respiratory support.
- C. Perform arterial blood gas analysis to assess oxygenation and ventilation.
- D. Recommend chest physiotherapy to promote airway clearance.
Correct Answer: B
Rationale: The correct answer is B: Initiate non-invasive positive pressure ventilation (NIPPV) for respiratory support. In acute exacerbations of COPD, NIPPV helps improve ventilation and oxygenation, reducing the work of breathing and preventing the need for intubation. This intervention is a priority as it can rapidly stabilize the patient's respiratory status.
A: Administering bronchodilator medications is important in COPD management, but in severe exacerbations, NIPPV takes precedence.
C: Arterial blood gas analysis is important for assessing oxygenation and ventilation status, but it does not directly address the acute respiratory distress.
D: Chest physiotherapy can help with airway clearance in COPD, but in acute exacerbations, respiratory support with NIPPV is more urgent.
The physician inserted a chest tube drainage to Mr. Alda in order to help re-expand the lungs. Which of the following should you prepare FIRST as a nurse in case of emergency when the tube is accidentally disconnected?
- A. sterile clamps
- B. Sterile dressing.
- C. Another chest tube
- D. A bottle of sterile water.
Correct Answer: A
Rationale: Correct Answer: A - sterile clamps
Rationale:
1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space.
2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space.
3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection.
4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation.
Summary of other choices:
B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space.
C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube.
D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.
A patient with a suspected autoimmune disorder exhibits antibodies directed against self-antigens, leading to tissue damage and inflammation. Which of the following mechanisms is primarily responsible for the development of autoimmune diseases?
- A. Loss of self-tolerance
- B. Failure of innate immunity
- C. Defective T cell activation
- D. Impaired phagocytosis
Correct Answer: A
Rationale: The correct answer is A: Loss of self-tolerance. This is because autoimmune diseases result from a breakdown in the immune system's ability to distinguish between self and non-self antigens, leading to the production of antibodies against self-antigens. When self-tolerance is lost, immune cells mistakenly target the body's own tissues, causing tissue damage and inflammation.
Choice B (Failure of innate immunity) is incorrect because autoimmune diseases are primarily driven by adaptive immunity rather than innate immunity. Choice C (Defective T cell activation) is incorrect as T cells play a critical role in the immune response to self-antigens in autoimmune diseases. Choice D (Impaired phagocytosis) is incorrect as phagocytosis is a mechanism primarily involved in the removal of pathogens, not in the development of autoimmune diseases.
Bel1le has a difficulty tolerating frustration The GOAL Of the nurse is to assist Belle to ________.
- A. increase her self-esteem
- B. recognize her need
- C. cope with anxiety
- D. mobilize her resources
Correct Answer: C
Rationale: The correct answer is C: cope with anxiety. The nurse's goal is to address Belle's difficulty tolerating frustration, which likely leads to anxiety. By helping Belle develop coping strategies for managing her anxiety, the nurse can assist her in handling frustration more effectively. Options A, B, and D are incorrect because increasing self-esteem, recognizing needs, and mobilizing resources may be important aspects of Belle's overall care but are not directly related to addressing her difficulty with frustration and anxiety. Focusing on coping with anxiety directly targets the root issue and is the most appropriate goal in this context.
A postpartum client who delivered via cesarean section expresses discomfort when ambulating and performing activities of daily living. What nursing intervention should be prioritized to promote optimal recovery?
- A. Encouraging early ambulation and progressive activity as tolerated
- B. Administering oral analgesics on a fixed schedule around the clock
- C. Restricting movement to prevent disruption of the incision site
- D. Applying heat packs to the incision site for pain relief
Correct Answer: A
Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.