Nokea
A patient presents with a pruritic, erythematous rash with scaly plaques and satellite papules and pustules in the inguinal folds and gluteal cleft. The patient reports recent antibiotic use for a urinary tract infection. Which of the following conditions is most likely responsible for this presentation?
- A. Candidiasis (cutaneous candidiasis)
- B. Tinea cruris (jock itch)
- C. Erythrasma
- D. Intertrigo
Correct Answer: A
Rationale: The presentation described indicates a candidal infection, which commonly occurs in warm, moist body areas like inguinal folds and gluteal cleft. The pruritic, erythematous rash with scaly plaques and satellite papules and pustules is characteristic of cutaneous candidiasis. The recent antibiotic use for urinary tract infection likely disrupted the normal skin flora, predisposing the patient to a Candida overgrowth. Tinea cruris (jock itch) can also present similarly, but the presence of satellite papules and pustules is more indicative of candidiasis. Erythrasma typically presents as well-defined brown-red patches without satellite lesions, and intertrigo is a more generic term referring to inflammation of skin folds that can have various causes, including candidiasis.
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A postpartum client expresses concern about feeling lightheaded when standing up. What should the nurse prioritize in the assessment to address this issue?
- A. Checking blood pressure
- B. Assessing for postural hypotension
- C. Evaluating hemoglobin levels
- D. Monitoring for signs of hemorrhage
Correct Answer: B
Rationale: Postural hypotension, also known as orthostatic hypotension, is a common issue postpartum and can cause lightheadedness when standing up. When a postpartum client expresses concern about feeling lightheaded, assessing for postural hypotension should be a priority. This assessment involves measuring the client's blood pressure while lying down, sitting, and standing to identify any significant drops in blood pressure upon changing positions. Identifying postural hypotension early allows for appropriate interventions to prevent potential falls and address the client's symptoms. Checking blood pressure, evaluating hemoglobin levels, and monitoring for signs of hemorrhage are also important assessments but may not directly address the specific issue of feeling lightheaded when standing up in this scenario.
Which endocrine disorder is most likely responsible for these symptoms?
- A. Hashimoto's thyroiditis
- B. Graves' disease
- C. Diabetes mellitus
- D. Thyroid nodules
Correct Answer: B
Rationale: The symptoms described—tachycardia, weight loss, and tremors—are consistent with hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism and is an autoimmune disorder in which the thyroid gland is overactive. This condition can lead to an increased production of thyroid hormones, resulting in symptoms such as rapid heartbeat (tachycardia), unintended weight loss, and tremors. In contrast, Hashimoto's thyroiditis is an autoimmune disorder that causes hypothyroidism, leading to symptoms like fatigue, weight gain, and cold intolerance. Diabetes mellitus is a metabolic disorder characterized by high blood sugar levels, which typically presents with symptoms such as increased thirst, frequent urination, and fatigue. Thyroid nodules are growths within the thyroid gland that can sometimes be associated with overactive (hyperthyroidism) or underactive (hypothyroidism) thyroid function, but they do not
Which should be emhpasize by the nurse in her health teachings
- A. Jogging a mile a day
- B. Vigourous exercise
- C. No need to diet
- D. Weight reduction
Correct Answer: D
Rationale: Weight reduction is the most important focus in the health teachings provided by the nurse. Maintaining a healthy weight is crucial for overall well-being and can significantly reduce the risk of various health conditions such as heart disease, diabetes, and certain cancers. By emphasizing weight reduction, the nurse can help improve the patient's overall health and quality of life. Jogging a mile a day and vigorous exercise are beneficial for weight management, but it is important to address the root cause of potential health problems which in this case may be excess weight. Moreover, emphasizing the importance of weight reduction does not necessarily mean encouraging extreme dieting; instead, it involves promoting a balanced and healthy approach to eating and physical activity.
A postpartum client who experienced a third-degree perineal laceration expresses concerns about the healing process and potential complications. What nursing intervention should be prioritized to promote optimal wound healing?
- A. Providing perineal care using peri-bottles with warm water
- B. Instructing the client on proper peri-pad application to the incision
- C. Encouraging the use of sitz baths for pain relief and wound cleansing
- D. Monitoring the incision site for signs of infection or dehiscence
Correct Answer: D
Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.
Nurse Cris received information from some community residents who suspect that a neighbor ls abusing his young child. Which should be the PRIORITY nursing action ?
- A. Report the police authorities.
- B. Notify the social worker.
- C. Ignore the information
- D. Validate the information
Correct Answer: A
Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.