Nokea
A postpartum client who experienced a traumatic birth expresses concerns about breastfeeding difficulties and emotional distress. What nursing intervention should be prioritized to address the client's concerns?
- A. Providing emotional support and empathy for the client's experience
- B. Recommending cessation of breastfeeding to alleviate stress
- C. Encouraging the client to avoid discussing the birth experience
- D. Referring the client to a mental health professional for counseling
Correct Answer: A
Rationale: Providing emotional support and empathy for the client's experience should be prioritized to address concerns of a postpartum client who experienced a traumatic birth. Emotional support can help the client feel validated and heard, which can be instrumental in starting the healing process. By acknowledging the client's emotions and experiences, the nurse can establish trust and create a safe space for the client to express their feelings. This can also help in building a therapeutic relationship that can positively impact the client's emotional well-being. Providing a supportive environment is essential for addressing breastfeeding difficulties and emotional distress in this situation.
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A patient presents with petechiae, purpura, and mucosal bleeding. Laboratory tests reveal thrombocytopenia, elevated serum creatinine, and schistocytes on peripheral blood smear. Which of the following conditions is most likely to cause these findings?
- A. Thrombotic thrombocytopenic purpura (TTP)
- B. Idiopathic thrombocytopenic purpura (ITP)
- C. Hemolytic uremic syndrome (HUS)
- D. Disseminated intravascular coagulation (DIC)
Correct Answer: A
Rationale: Thrombotic thrombocytopenic purpura (TTP) is a rare but serious condition characterized by microangiopathic hemolytic anemia, thrombocytopenia, neurological abnormalities, fever, and renal dysfunction. The classic pentad of symptoms includes fever, neurologic changes, renal impairment, thrombocytopenia, and microangiopathic hemolytic anemia. The presence of petechiae, purpura, and mucosal bleeding along with thrombocytopenia, elevated serum creatinine, and schistocytes on peripheral blood smear are consistent with TTP. In TTP, there is usually a deficiency of ADAMTS13 (a von Willebrand factor-cleaving protease) leading to excessive platelet adhesion, aggregation, and microthrombi formation within small blood vessels. Treatment typically
A nurse is preparing to assist with a percutaneous endoscopic gastrostomy (PEG) tube insertion for a patient requiring long-term enteral feeding. What action should the nurse prioritize to ensure procedural success?
- A. Confirming the patient's fasting status before the PEG tube insertion
- B. Positioning the patient in a supine position with the head of the bed elevated
- C. Administering prophylactic antibiotics to prevent infection
- D. Coordinating with radiology or gastroenterology for procedural guidance Dermatology
Correct Answer: D
Rationale: Coordinating with radiology or gastroenterology for procedural guidance is crucial to ensure the success of a percutaneous endoscopic gastrostomy (PEG) tube insertion. This procedure is typically performed under endoscopic guidance to ensure proper placement of the tube into the stomach through the abdominal wall. Radiology or gastroenterology professionals are trained to perform and guide the insertion procedure, making their involvement essential for a successful outcome. Additionally, their expertise helps minimize the risk of complications during and after the PEG tube placement.
In admitting the injured patients, which of the following should be the FIRST that should be done by the emergency team? They should assess the patients ________.
- A. Breathing
- B. Circulation
- C. Airway
- D. Vital signs
Correct Answer: C
Rationale: Assessing the patient's airway is the first priority when admitting injured patients. A clear airway is crucial for effective breathing. If the airway is obstructed, the patient will not be able to breathe properly, leading to serious consequences. Therefore, ensuring a patent airway takes precedence over assessing breathing, circulation, or vital signs. Once the airway is secured, the emergency team can proceed with assessing breathing, circulation, and vital signs in order to provide appropriate treatment and care.
Which nursing diagnosis is NOT RELEVANT to sexual health?
- A. Anxiety-related inability to conceive after six months .
- B. Health-seeking behaviors related to reproductive functioning
- C. Sexual dysfunction related to an unknown cause.
- D. Risk for infection related to high-risk. sexual behaviors.
Correct Answer: B
Rationale: In the given situation, the nursing diagnosis that is NOT RELEVANT to sexual health is option B, Health-seeking behaviors related to reproductive functioning. This diagnosis focuses on the patient's proactive approach to seeking healthcare services related to reproductive health matters. However, in the situation presented of a pregnant patient with sickle cell anemia experiencing fever, painful swelling, and in labor pain, the immediate priority lies in addressing the health issues related to sickle cell disease and the current pregnancy. Sexual health is not the primary concern in this scenario compared to managing the complications of sickle cell anemia during pregnancy. Therefore, the diagnosis related to health-seeking behaviors related to reproductive functioning is not as pertinent in this specific case.
A patient is prescribed an antipsychotic medication for the management of schizophrenia. Which adverse effect should the nurse monitor closely in the patient?
- A. Hypertension
- B. Hypoglycemia
- C. Extrapyramidal symptoms
- D. Hypercalcemia
Correct Answer: C
Rationale: Antipsychotic medications, especially first-generation antipsychotics, can cause extrapyramidal symptoms (EPS) as an adverse effect. EPS include symptoms such as muscle rigidity, tremors, akathisia (restlessness), and tardive dyskinesia (involuntary movements of the face and body). These symptoms are due to the medications' effects on the dopamine system in the brain. It is crucial for the nurse to monitor the patient closely for EPS because they can be uncomfortable, distressing, and may impact the patient's quality of life and medication adherence. Early recognition and management of EPS are essential to prevent further complications and improve the patient's overall well-being.