Nokea
A postpartum client who had an episiotomy expresses concern about the appearance and healing of the incision site. What nursing intervention should be prioritized to promote optimal wound healing?
- A. Encouraging frequent perineal hygiene with soap and water
- B. Applying antibiotic ointment to the incision site after each void
- C. Providing perineal care using peri-bottles with warm water
- D. Instructing the client on proper peri-pad application to the incision
Correct Answer: C
Rationale: The priority nursing intervention to promote optimal wound healing in a client who had an episiotomy is providing perineal care using peri-bottles with warm water. Warm water helps to cleanse the area, reduce the risk of infection, and promote circulation, which aids in wound healing. Peri-bottles are especially gentle and effective in cleaning the perineal area without causing trauma to the incision site. Encouraging frequent perineal hygiene with soap and water may be too harsh on the incision site and could lead to irritation. Applying antibiotic ointment after each void is not necessary unless prescribed by the healthcare provider, as overuse of antibiotics can lead to resistance. Instructing the client on proper peri-pad application is important for comfort and cleanliness but is not as crucial as gentle perineal care using peri-bottles with warm water for promoting optimal wound healing.
You may also like to solve these questions
A patient with a history of sickle cell disease presents with severe abdominal pain, fever, and jaundice. Laboratory tests reveal anemia, reticulocytosis, elevated indirect bilirubin, and presence of Howell-Jolly bodies on peripheral blood smear. Which of the following conditions is most likely to cause these findings?
- A. Acute splenic sequestration crisis
- B. Aplastic crisis
- C. Hemolytic crisis
- D. Vaso-occlusive crisis
Correct Answer: A
Rationale: Acute splenic sequestration crisis is a complication seen in patients with sickle cell disease characterized by the sudden pooling of sickled red blood cells in the spleen, leading to splenic enlargement, severe anemia, and hypovolemic shock. This pooling results in a rapid drop in hemoglobin levels, causing anemia. The spleen's sequestration of large numbers of red blood cells can cause a sudden rise in the number of immature red blood cells (reticulocytes) in the blood (reticulocytosis). The destruction of these trapped red blood cells in the spleen leads to hemolysis, evidenced by elevated indirect bilirubin levels and the presence of Howell-Jolly bodies (nuclear remnants of erythrocytes) on peripheral blood smear. Patients may present with severe abdominal pain, fever, jaundice, and signs of hemodynamic instability, which
Choose the step of nursing process that identiffies the famiilyy health seeking behavior.
- A. Assesment
- B. Planning
- C. Implementation
- D. Evaluation Situation
Correct Answer: A
Rationale: The step of the nursing process that identifies the family's health-seeking behavior is Assessment. During the assessment phase, the nurse gathers information about the family's health practices, beliefs, priorities, and past experiences related to seeking healthcare. This helps the nurse understand how the family approaches health and healthcare, which is crucial for providing tailored and effective care. By assessing the family's health-seeking behavior, the nurse can better collaborate with them to address their health needs and promote positive health outcomes.
A patient presents with a palpable, non-tender mass in the right neck, just below the angle of the mandible. Ultrasound imaging demonstrates a well-defined, hypoechoic lesion with cystic components. Which of the following conditions is most likely responsible for this presentation?
- A. Branchial cleft cyst
- B. Thyroglossal duct cyst
- C. Lymphadenopathy
- D. Parotid gland tumor
Correct Answer: A
Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.
The mother of the family asked Nurse Emma how to apply the anti -scabies lotion. The nurse should teach the family to apply anti -scabies lotion to _________.
- A. all skin areas
- B. open lesions
- C. affected skin
- D. Reddened areas
Correct Answer: A
Rationale: The correct way to apply anti-scabies lotion is to cover all skin areas, not just the affected areas or red areas. Scabies is a contagious skin condition caused by mites burrowing into the skin, so applying the lotion to all skin areas helps to eliminate the mites and prevent reinfestation. It is important to follow the instructions provided by the healthcare professional for proper application and treatment of scabies.
A patient presents with chest pain that worsens with exertion and improves with rest. An electrocardiogram (ECG) shows ST-segment depression. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Acute myocardial infarction
- D. Prinzmetal's angina
Correct Answer: A
Rationale: The patient is presenting with chest pain that worsens with exertion and improves with rest, which is characteristic of stable angina. Additionally, ST-segment depression on ECG is a common finding in patients with stable angina. Stable angina is typically caused by coronary artery disease, which leads to partial obstruction of the coronary arteries resulting in inadequate blood flow to the heart muscle during periods of increased demand (such as exertion). The chest pain is usually predictable and reproducible, occurring with similar intensity and duration during episodes of exertion. Rest or nitroglycerin can help relieve the symptoms by increasing coronary blood flow. It is important to differentiate stable angina from unstable angina and acute myocardial infarction, which have different management and prognostic implications.