Nokea
A postpartum client presents with sudden, severe chest pain and dyspnea. Which nursing action is most appropriate?
- A. Placing the client in a semi-Fowler's position
- B. Administering supplemental oxygen therapy
- C. Notifying the healthcare provider immediately
- D. Encouraging the client to perform deep breathing exercises
Correct Answer: C
Rationale: Sudden, severe chest pain and dyspnea in a postpartum client could be indicative of a potential serious condition, such as a pulmonary embolism or postpartum cardiomyopathy, which require immediate medical attention. Therefore, the most appropriate nursing action would be to notify the healthcare provider immediately for further evaluation and management. Placing the client in a semi-Fowler's position may provide some comfort but does not address the underlying cause of the symptoms. Administering supplemental oxygen therapy may be necessary once the healthcare provider assesses the client. Encouraging deep breathing exercises may not be appropriate if the client is experiencing severe chest pain and dyspnea, as it could worsen the situation.
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Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?
- A. Rapid progressive muscular atrophy.
- B. Ascending paralysis with ataxia .
- C. Hyperactive deep tendon reflexes
- D. Paresthesia and muscle weakness of upper body.
Correct Answer: D
Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.
A patient presents with a thyroid nodule and signs of hyperthyroidism. Fine-needle aspiration biopsy reveals Hurthle cells and cellular atypia. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hashimoto's thyroiditis
- B. Graves' disease
- C. Hurthle cell carcinoma
- D. Papillary thyroid carcinoma
Correct Answer: C
Rationale: Hurthle cell carcinoma is a type of thyroid cancer that arises from the Hurthle cells of the thyroid gland. Patients with Hurthle cell carcinoma may present with a thyroid nodule and signs of hyperthyroidism, which can mimic other thyroid disorders such as Graves' disease. Fine-needle aspiration biopsy revealing Hurthle cells and cellular atypia is suggestive of a Hurthle cell neoplasm, particularly Hurthle cell carcinoma. It is important to differentiate Hurthle cell carcinoma from benign Hurthle cell adenomas or other thyroid conditions to guide appropriate management and treatment.
Where should the nurse dispose used wet diaper and gloves?
- A. Green
- B. Red
- C. Black
- D. Yellow
Correct Answer: C
Rationale: Used wet diapers and gloves should be disposed of in a black waste bin. Black waste bins are designated for general waste, which includes non-infectious materials that do not pose a risk of infection to others. Wet diapers and gloves fall under this category as they are considered non-infectious waste. Proper disposal in the black bin helps in maintaining cleanliness and hygiene in the healthcare setting.
Which of the following energy conserving strategies should NOT be done by COPD patients?
- A. Exhale when pushing or exerting effort when doing daily activities
- B. Assume tripod position with elbows supported on the table when shaving or combing
- C. Inhale when resting, sitting and lying down.
- D. Stand in front of the mirror while shaving or combing hair
Correct Answer: D
Rationale: COPD (Chronic Obstructive Pulmonary Disease) patients often struggle with breathing difficulties due to their conditions, hence it is important for them to conserve their energy as much as possible. Standing while performing activities like shaving or combing hair can be physically demanding for COPD patients as it requires more energy and can lead to increased shortness of breath. It is recommended for COPD patients to sit down or assume a supported position (like the tripod position with elbows supported on a table) to reduce the energy expended and minimize the strain on their respiratory system. Standing in front of the mirror while performing grooming activities is a task that can be easily modified to a seated position, thus conserving energy and reducing the risk of exacerbating breathing difficulties for COPD patients.
The false statement about physiologic jaundice in the statements below is _____
- A. Caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase.
- B. Begins to decrease by the 6th or 7th day.
- C. Is visible in skin and sclera.
- D. Begins after 48 hours of 1ife.
Correct Answer: A
Rationale: Physiologic jaundice in newborns is a common and typically benign condition caused by the immaturity of the newborn's liver. The correct statement about physiologic jaundice is that it occurs due to an imbalance between the production and elimination of bilirubin. In contrast, Option A is the false statement because it incorrectly states that physiologic jaundice is caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase. This statement is inaccurate as physiologic jaundice results from the immature liver's reduced ability to conjugate bilirubin.