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A patient with suspected acute exacerbation of asthma presents with severe dyspnea, accessory muscle use, and inability to speak in full sentences. Which of the following interventions is most appropriate for assessing the severity of the patient's asthma exacerbation and guiding management decisions?
- A. Peak expiratory flow rate (PEFR) measurement
- B. Arterial blood gas (ABG) analysis
- C. Chest X-ray
- D. Clinical assessment using standardized severity scores
Correct Answer: D
Rationale: In the scenario described, the patient is presenting with severe symptoms of acute exacerbation of asthma, including severe dyspnea, accessory muscle use, and inability to speak in full sentences. In such cases, the most appropriate intervention for assessing the severity of the asthma exacerbation and guiding management decisions is a clinical assessment using standardized severity scores.
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Which of the following is an example of a barrier to successful negotiation?
- A. Avoiding phrases that are coercive
- B. Becoming emotional
- C. Viewing negotiation as collaborative
- D. Understanding others' perspectives
Correct Answer: B
Rationale: Becoming emotional is an example of a barrier to successful negotiation because emotions can cloud judgment, lead to irrational decision-making, and hinder effective communication. When negotiating, it is important to remain calm, composed, and rational to navigate the discussion effectively. Emotions can derail the negotiation process, making it challenging to find common ground and reach a mutually beneficial agreement.
In a conscious trauma patient with a suspected head injury, which of the following actions is appropriate?
- A. Applying direct pressure to the wound.
- B. Administering aspirin for pain relief.
- C. Maintaining cervical spine immobilization.
- D. Assessing pupil reaction to light.
Correct Answer: C
Rationale: In a conscious trauma patient with a suspected head injury, maintaining cervical spine immobilization is crucial. The presence of a head injury raises concerns for potential concomitant cervical spine injury. Therefore, it is vital to prevent any movement of the cervical spine to avoid exacerbating a potential spinal cord injury. Maintaining immobilization involves stabilizing the patient's head and neck in a neutral position until appropriate imaging studies can assess the extent of any spinal injury. This action helps prevent further harm and ensures the safety of the patient during assessment and management of their injuries.
Nurse Roberto assists in the care of a 30 year old male post surgical client undergoing nasogastric suctioning. The nurse understands that clients with nasogastric suction is MOST at risks with what imbalances?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Metabolic acidosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: Clients undergoing nasogastric suctioning are at highest risk for developing metabolic imbalances, specifically metabolic acidosis. Nasogastric suctioning can lead to the loss of gastric acid, which in turn can cause metabolic acidosis due to a decrease in bicarbonate levels in the body. This disruption in the acid-base balance can result in symptoms such as confusion, headache, and overall malaise. It is crucial for the nurse to monitor the client's acid-base status closely and provide appropriate interventions to prevent or correct metabolic acidosis.
A 32-year-old pregnant woman presents with painless vaginal bleeding at 10 weeks of gestation. On ultrasound, a gestational sac with no embryo is visualized within the uterus. Which of the following conditions is most likely to be responsible for these findings?
- A. Threatened abortion
- B. Inevitable abortion
- C. Missed abortion
- D. Ectopic pregnancy
Correct Answer: C
Rationale: In a missed abortion, the embryo has died, but the products of conception remain in the uterus, leading to the visualization of a gestational sac without an embryo on ultrasound. This is a type of missed miscarriage where the woman may not have any symptoms initially and the diagnosis is made during a routine ultrasound. The most common presenting symptom is painless vaginal bleeding. The absence of an embryo within the gestational sac can be confirmed through serial ultrasound examinations showing no fetal growth or cardiac activity. It is important for healthcare providers to provide appropriate counseling and management options to support the patient through this emotional experience.
A postpartum client who delivered vaginally expresses concern about feeling "heavy" in the perineal area. What education should the nurse provide to address this sensation?
- A. Encourage the client to perform Kegel exercises regularly.
- B. Recommend the use of perineal pads for additional support.
- C. Educate the client about the process of uterine involution.
- D. Suggest the use of a perineal support garment.
Correct Answer: A
Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.