Nokea
A postpartum client exhibits signs of depression, including tearfulness, feelings of guilt, and decreased interest in self-care. Which nursing intervention should be prioritized?
- A. Encouraging participation in support groups for new mothers
- B. Referring the client to a mental health professional for counseling
- C. Administering antidepressant medication as prescribed
- D. Assessing for risk of harm to self or infant
Correct Answer: D
Rationale: The prioritized nursing intervention in this situation should be assessing for the risk of harm to self or infant. It is crucial to ensure the safety of the postpartum client and her infant as depression can increase the risk of self-harm or harm to the newborn. By assessing for any potential risks, the nurse can take appropriate actions to prevent any harm and ensure the well-being of both the client and the infant. Once the assessment is completed, further interventions like encouraging participation in support groups, referring to a mental health professional, or administering medications can be considered based on the assessment findings.
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A patient with a history of chronic liver disease presents with bruising, petechiae, and mucosal bleeding. Laboratory tests reveal prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) with decreased platelet count. Which of the following conditions is most likely to cause these findings?
- A. Immune thrombocytopenic purpura (ITP)
- B. Disseminated intravascular coagulation (DIC)
- C. Hemophilia A
- D. Von Willebrand disease
Correct Answer: B
Rationale: Disseminated intravascular coagulation (DIC) is a condition characterized by widespread activation of coagulation leading to both thrombosis and hemorrhage. In patients with chronic liver disease, especially in the setting of advanced cirrhosis, DIC can develop due to factors such as decreased synthesis of coagulation factors and impaired clearance of activated clotting factors. The patient in this scenario presents with signs of both abnormal bleeding (bruising, petechiae, mucosal bleeding) and laboratory findings consistent with DIC, including prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) along with decreased platelet count.
The best prevention management of contact latex allergy is ______.
- A. applying lotion before gloving
- B. avoidance of latex products
- C. avoiding rubberized goods
- D. resigning from the job
Correct Answer: B
Rationale: The best prevention management of contact latex allergy is to avoid latex products entirely. Latex allergies can range from mild skin irritation to severe reactions such as anaphylaxis. This means that even applying lotion before using latex gloves may not be sufficient to prevent an allergic reaction in individuals who are sensitized to latex. It is important for individuals with latex allergy to completely avoid exposure to latex products, including rubberized goods, to prevent triggering an allergic response. Resigning from the job is not a practical solution and should not be necessary if proper precautions are taken to avoid latex exposure.
In the tertiary hospital where the patient is referred , he was considered an emergency case. The nurse immediately call for a specialist who is ______.
- A. Neurologist
- B. Plebotomist
- C. Urologist
- D. Nephrologist
Correct Answer: A
Rationale: In the scenario described, the patient was considered an emergency case upon referral to the tertiary hospital. Since a specialist was immediately called for by the nurse, the most likely specialist needed in an emergency situation is a neurologist. Neurologists are physicians who specialize in diagnosing and treating disorders of the nervous system, including the brain, spinal cord, and nerves. In an emergency case where a patient's neurological condition needs urgent attention, a neurologist would be the most appropriate specialist to address the situation promptly and effectively.
Which of the following is caused by the markedly distended uterus and intermittent uterine contractions within 2 to 3 days after birth?
- A. Retained placenta
- B. Uterine atony
- C. Afterpains
- D. Boggy uterus
Correct Answer: B
Rationale: Uterine atony is caused by the markedly distended uterus and intermittent uterine contractions within 2 to 3 days after birth. It is characterized by the inability of the uterus to contract after delivery, leading to excessive bleeding postpartum. This condition is a significant risk factor for postpartum hemorrhage. Treatment may involve massage of the uterus, administration of uterotonics, and in severe cases, surgical interventions such as a hysterectomy. Retained placenta refers to incomplete expulsion of the placenta after delivery. Afterpains are the discomfort felt by some women as their uterus contracts and returns to its normal size after childbirth. A boggy uterus is another term for a uterus that feels soft, lax, or lack firm tone, which can be a sign of uterine atony.
Which of the following charting rules will keep the nurse legally safe? I. Documenting worries and all concerns as verbalized by the patient. II Charting at the end of the shift only. III.Discussing of recorded cases and diagnosis of the patient. IV. Recording all information verbalized by patient and family.
- A. III, IV
- B. I
- C. I, III
- D. II
Correct Answer: B
Rationale: The correct charting rule to keep the nurse legally safe is to document worries and all concerns as verbalized by the patient (Choice I). This is important for accurately reflecting the patient's condition, communication, and potential interventions. Charting at the end of the shift only (Choice II) is not recommended as it can lead to missed important details or delayed documentation. Discussing recorded cases and diagnoses of the patient (Choice III) breaches patient confidentiality and violates HIPAA laws. Recording all information verbalized by the patient and family (Choice IV) may include unnecessary details and could potentially lead to misinterpretation or misunderstanding, which might not be legally advantageous.