Nokea
As to the observance of respecting privacy, nurse Trining explained about___________.
- A. breach of contract
- B. Ethical dilemma
- C. anonymity
- D. Confidentiality
Correct Answer: D
Rationale: Nurse Trining explained about confidentiality in relation to observing respect for privacy. Confidentiality is the duty to keep patient information private and not disclose it without the patient's consent. It is a fundamental principle in healthcare that helps build trust between patients and healthcare providers. By maintaining confidentiality, healthcare professionals uphold the ethical obligation to protect patients' privacy and sensitive information, ensuring that they feel safe and respected during their interactions with the healthcare system.
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A patient presents with a small, painless, well-defined nodule on the lateral aspect of the neck, just above the clavicle. Fine-needle aspiration cytology reveals clusters of polygonal cells with abundant granular cytoplasm. Which of the following conditions is most likely responsible for this presentation?
- A. Thyroglossal duct cyst
- B. Branchial cleft cyst
- C. Lymphadenopathy
- D. Parathyroid adenoma
Correct Answer: D
Rationale: The presentation described is characteristic of a parathyroid adenoma. Parathyroid adenomas are benign neoplasms that can present as painless, well-defined nodules usually located in the lower pole of the thyroid gland or in close proximity, such as the lateral aspect of the neck above the clavicle. Fine-needle aspiration cytology of a parathyroid adenoma typically reveals polygonal cells with abundant granular cytoplasm, often referred to as chief cells. This is key in differentiating it from other conditions mentioned in the question.
The patient began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The patient complains of difficulty of breathing, itching and a tight sensation in the chest. Which is the IMMEDIATE action of the nurse?
- A. Recheck the unit of blood for compatibility.
- B. Call the physician.
- C. Check the patient 's temperature.
- D. Stop the infusion.
Correct Answer: D
Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.
The client has been "pesky," seeking the attention of nurses in the nurses' station much of the day. Now the nurse escorts the client to the room and tells the client to stay there or be put into seclusion. The nurse is threatening to give the client an injection in order to restrain the client for inappropriate behavior. This is an example of
- A. Abuse
- B. Assault
- C. False imprisonment
- D. Battery
Correct Answer: C
Rationale: False imprisonment is the act of improperly restraining another individual against their will. In this scenario, the nurse's threat of putting the client into seclusion and administering an injection to restrain them for inappropriate behavior constitutes false imprisonment. The client is being restricted in their movement without valid reason or proper procedure. This type of action is not acceptable in healthcare settings and violates the client's rights. It is important for healthcare professionals to use appropriate de-escalation techniques and interventions to manage challenging behaviors without resorting to threats of physical restraint.
What symptom is an INDICATOR of cranial nerve involvement?
- A. Difficulty of speaking and chewing.
- B. Loss of pain sensation
- C. Spastic paralysis of the extremities
- D. Forgetfulness and syncope
Correct Answer: A
Rationale: Difficulty of speaking and chewing is an indicator of cranial nerve involvement. Cranial nerves are responsible for controlling various functions of the head and neck, including speech and mastication. Impairment of cranial nerve function can lead to difficulty in these activities. In the context of the question, with the patient in the stroke unit, cranial nerve involvement can occur due to the stroke affecting the brain regions responsible for cranial nerve function. Loss of pain sensation, spastic paralysis of the extremities, and forgetfulness with syncope are not specific indicators of cranial nerve involvement in this scenario.
After administering anesthesia to the patient, the nurse notices a sudden drop in blood pressure. What is the nurse's priority action?
- A. Administer vasopressors to increase blood pressure
- B. Assess the patient's airway, breathing, and circulation
- C. Document the blood pressure readings in the anesthesia record
- D. Notify the anesthesiologist immediately
Correct Answer: B
Rationale: The nurse's priority action after noticing a sudden drop in blood pressure after administering anesthesia is to assess the patient's airway, breathing, and circulation (ABCs). This is crucial to determine the immediate cause of the sudden drop in blood pressure and to ensure the patient's safety and stability. Assessment of the ABCs will help identify any potential airway obstruction, respiratory distress, or circulatory issues that may be contributing to the drop in blood pressure. Once the assessment is done, appropriate interventions can be initiated to stabilize the patient's condition. Administering vasopressors, documenting the blood pressure readings, and notifying the anesthesiologist are important actions but assessing the ABCs takes precedence in this situation to ensure the patient's immediate needs are addressed.