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After positioning the patient for surgery, the nurse notices signs of pressure injury on the patient's heels. What should the nurse do?
- A. Apply pressure-relieving devices to the heels
- B. Document the findings in the patient's chart
- C. Reposition the patient to relieve pressure
- D. Notify the surgeon about the pressure injuries
Correct Answer: A
Rationale: Pressure injuries on the heels are a concern as they can develop quickly and lead to serious complications, especially in surgical patients who are immobile for extended periods. Applying pressure-relieving devices, such as heel protectors or foam dressings, can help alleviate the pressure on the affected areas and prevent further damage. These devices are designed to distribute pressure evenly and reduce the risk of pressure injuries. It is important for the nurse to address the issue promptly to prevent additional harm to the patient's skin integrity.
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When the nurse researcher collects data at more than one point over an extended period, which design is applied?
- A. Cross-sectional
- B. Time sequenced
- C. Time-related
- D. Longitudinal
Correct Answer: D
Rationale: In a longitudinal study design, the nurse researcher collects data at multiple points over an extended period of time. This design allows for the examination of changes or trends over time within the same group of participants. It helps in understanding the long-term effects and relationships between variables by tracking the same individuals over a prolonged duration. This design is particularly useful in studying developmental patterns, chronic diseases, or long-term treatment outcomes.
A patient presents with recurrent episodes of joint pain, swelling, and limited range of motion in multiple joints. Laboratory tests reveal elevated erythrocyte sedimentation rate (ESR), positive rheumatoid factor (RF), and presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies. Which of the following conditions is most likely to cause these findings?
- A. Rheumatoid arthritis (RA)
- B. Systemic lupus erythematosus (SLE)
- C. Ankylosing spondylitis (AS)
- D. Psoriatic arthritis (PsA)
Correct Answer: A
Rationale: The combination of recurrent joint pain, swelling, and limited range of motion in multiple joints along with elevated ESR, positive RF, and presence of anti-CCP antibodies is classic for rheumatoid arthritis (RA). Elevated ESR indicates inflammation, positive rheumatoid factor (RF) is an autoantibody commonly found in the serum of patients with RA, and the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies further supports the diagnosis of RA. These laboratory findings along with the clinical presentation are highly suggestive of rheumatoid arthritis. Systemic lupus erythematosus (SLE), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) can have overlapping symptoms with RA, but the specific combination of elevated ESR, positive RF, and anti-CCP antibodies points more towards RA in this scenario.
Despite the short staffing, Nurse Cirila also has the responsibility to maintain safe environment for her pediatric patients. The following are the indicators that Nurse Cirila has achieved this goal, EXCEPT __________.
- A. Proper disposal of waste according to color coding
- B. Adherence to policies, protocols and procedures in the prevention and control of infection prevention.
- C. Assessing the competencies of a staff before delegating a task
- D. Observance of protocols in cases of earthquakes, fire and other emergencies.
Correct Answer: C
Rationale: The indicators listed indicate measures that Nurse Cirila can take to maintain a safe environment for her pediatric patients. However, assessing the competencies of staff before delegating a task is more related to ensuring effective delegation and appropriate task assignment rather than directly ensuring a safe environment for patients. While it is important to delegate tasks to qualified staff, this specific action does not directly contribute to maintaining a safe environment in the same manner as the other indicators listed (proper waste disposal, infection control, emergency protocols).
A postpartum client who is breastfeeding expresses concerns about breast engorgement and discomfort. What nursing intervention should be prioritized to alleviate symptoms?
- A. Encouraging frequent breastfeeding or pumping sessions
- B. Applying cold packs to the breasts between feedings
- C. Recommending the use of a supportive bra or breast binder
- D. Administering oral analgesics for pain relief
Correct Answer: A
Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.
A patient presents with a sensation of a foreign body stuck in the throat, difficulty swallowing, and odynophagia. Flexible laryngoscopy reveals a submucosal mass arising from the posterior pharyngeal wall. Which of the following conditions is most likely responsible for this presentation?
- A. Zenker's diverticulum
- B. Laryngopharyngeal reflux (LPR)
- C. Hypopharyngeal carcinoma
- D. Tonsillar hypertrophy
Correct Answer: A
Rationale: Zenker's diverticulum is a condition in which there is a pouch or sac that forms at the posterior pharyngeal wall above the upper esophageal sphincter. It can present with symptoms such as sensation of a foreign body stuck in the throat, difficulty swallowing (dysphagia), and odynophagia (painful swallowing). Flexible laryngoscopy can reveal a submucosal mass arising from the posterior pharyngeal wall, which is characteristic of Zenker's diverticulum.