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A postpartum client presents with persistent, severe headache, photophobia, and altered mental status. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Notifying the healthcare provider immediately
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action when a postpartum client presents with persistent, severe headache, photophobia, and altered mental status is to notify the healthcare provider immediately. These symptoms could be indicative of serious conditions such as postpartum preeclampsia or postpartum eclampsia, both of which require prompt medical evaluation and intervention. Delaying medical attention in such cases can lead to severe complications for the mother. Therefore, it is crucial to prioritize the client's safety and well-being by quickly involving the healthcare provider for further assessment and management.
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The young mother wanted to know about the motor development APPROPRIATE in a preschooler. Which of the following statements NOT true?
- A. "He can tie shoe lace"
- B. "He can alternate feet when climbing"
- C. "He has not developed good postures"
- D. "He can hop two or more times"
Correct Answer: B
Rationale: The statement that the preschooler can alternate feet when climbing is not true. Typically, preschoolers at this age group are still developing their coordination and may not have mastered the skill of alternating feet while climbing. It is more common for them to use one foot after the other while climbing. This skill usually requires more advanced motor development and coordination, which may come later in the preschool years.
It is not enough for the nurse to listen, but she also has, to validate what she has heard. The importance of validation are the following EXCEPT _____
- A. perceptions influence the interpretation of a message
- B. most patients are cognitively impaired
- C. Eye contact does not necessarily send the same message
- D. assists clarifying thoughts
Correct Answer: B
Rationale: The importance of validation in the context of communication and nursing care does not include the assumption that most patients are cognitively impaired. It would be more appropriate to approach patient interactions with the assumption that patients are capable of understanding and coherent communication. Validation is important because it helps ensure that the nurse has truly understood the patient's message, prevents misinterpretation, and fosters a sense of empathy and trust in the nurse-patient relationship. Additionally, validating the patient's thoughts and feelings can help clarify confused thoughts and promote effective communication. The other options (A, C, and D) are all valid reasons emphasizing the significance of validation in effective communication.
What should be the color of trash bin for the proper disposal of waste product such as papers from the admin office?
- A. Yellow
- B. green
- C. Black
- D. orange
Correct Answer: C
Rationale: The color black is commonly used for general waste or non-recyclable materials, which includes papers and other waste products typically found in an office setting. By designating a black trash bin for the proper disposal of these items, it helps in efficient waste management and ensures that they are disposed of correctly. This color coding system helps individuals easily identify which type of waste goes in which bin, promoting recycling and proper waste segregation practices in the office environment.
A patient presents with a Colles' fracture. What is the characteristic deformity associated with this type of fracture?
- A. Dorsal displacement of the distal fragment
- B. Ventral displacement of the distal fragment
- C. Lateral displacement of the distal fragment
- D. Medial displacement of the distal fragment
Correct Answer: A
Rationale: Colles' fracture is a type of distal radius fracture characterized by a break of the radius bone in the forearm close to the wrist. In a Colles' fracture, the distal fragment of the fractured radius bone gets displaced dorsally, meaning it shifts upwards towards the back of the hand, creating a characteristic "dinner fork" deformity when viewed from the side. This dorsal displacement results in a visible bump on the back of the wrist and a noticeable deformity when compared to the uninjured side.
A 38-year-old woman presents with cyclic pelvic pain, dysmenorrhea, and dyspareunia. On pelvic examination, the uterus is retroverted and fixed. Which of the following conditions is most likely to be responsible for these findings?
- A. Endometriosis
- B. Adenomyosis
- C. Leiomyomas (uterine fibroids)
- D. Pelvic inflammatory disease (PID)
Correct Answer: A
Rationale: Endometriosis is the most likely condition responsible for the symptoms described in this scenario. Endometriosis is a chronic condition in which endometrial-like tissue grows outside the uterus, commonly affecting the pelvic structures such as the ovaries, fallopian tubes, and pelvic peritoneum. The main symptoms include cyclic pelvic pain, dysmenorrhea (painful periods), and dyspareunia (pain during intercourse). The retroverted and fixed uterus on examination may be due to adhesions from endometriosis, causing the uterus to be fixed in position. Endometriosis should be considered in women of reproductive age presenting with these symptoms and pelvic examination findings.