Nokea
During surgery, the nurse observes a sudden change in the patient's level of consciousness. What is the nurse's immediate action?
- A. Administer a reversal agent for anesthesia
- B. Document the change in the patient's chart
- C. Check the patient's vital signs
- D. Notify the anesthesia provider immediately
Correct Answer: D
Rationale: The correct immediate action for the nurse is to notify the anesthesia provider immediately (Option D). This is crucial because a sudden change in the patient's level of consciousness during surgery could indicate a serious issue related to anesthesia administration. Notifying the anesthesia provider promptly allows for quick assessment and intervention to address the underlying cause, potentially preventing complications or even saving the patient's life. Administering a reversal agent (Option A) without proper evaluation by the anesthesia provider could be dangerous. Documenting the change in the patient's chart (Option B) is important but not the most immediate action. Checking the patient's vital signs (Option C) is also important but may not provide immediate insight into the cause of the change in consciousness.
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Nurse Chona read in one nurse's notes chart this documentation: "Refused to eat and fell from bed". Which of the following is lacking in this documentation?
- A. Time of complaint, for missed and reaction on fall incurred.
- B. Referrals made on fall medications given and reasons of falling.
- C. Contents or complaints, reasons of refusing meal and nature of fall.
- D. Time of eating, medications for back pain and intense of pain.
Correct Answer: C
Rationale: The correct answer is C because the documentation lacks essential details regarding the contents of the complaints, reasons for refusing the meal, and the nature of the fall. This information is crucial for understanding the patient's condition and providing appropriate care. Choice A is not directly related to the documentation provided. Choice B is about referrals and medications, which are not mentioned in the documentation. Choice D is about eating time and medications for pain, which are also not relevant to the documentation provided. Therefore, the correct answer is C as it addresses the specific missing information in the nurse's notes.
Nurse has a complaint from a parent for administering gwrong dose of vaccine to the child. This act is a form of _______.
- A. Battery
- B. Negligence
- C. Assault
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Negligence. Negligence refers to the failure to exercise the care that a reasonably prudent person would under similar circumstances. In this case, administering the wrong dose of a vaccine indicates a lack of proper care or attention to detail, which constitutes negligence.
A: Battery involves intentional harmful or offensive contact without consent, which is not applicable in this situation.
C: Assault involves the threat of harm or unwanted physical contact, which is also not relevant here.
D: Malpractice typically refers to professional misconduct or negligence by a healthcare provider, which could be a broader term but not specific to the situation described.
A patient with a history of chronic liver disease presents with ecchymoses, mucosal bleeding, and altered mental status. Laboratory tests reveal prolonged PT and aPTT, low fibrinogen levels, and elevated D-dimer. Which of the following conditions is most likely to cause these findings?
- A. Liver cirrhosis
- B. Disseminated intravascular coagulation (DIC)
- C. Hemophilia A
- D. Vitamin K deficiency
Correct Answer: B
Rationale: The correct answer is B: Disseminated intravascular coagulation (DIC). In DIC, there is widespread activation of coagulation leading to consumption of clotting factors, resulting in prolonged PT and aPTT, low fibrinogen levels, and elevated D-dimer. This pattern matches the laboratory findings in the patient. In liver cirrhosis (choice A), there is a decrease in clotting factors synthesis, leading to prolonged PT but not aPTT. Hemophilia A (choice C) is a genetic disorder that affects specific clotting factors, typically leading to prolonged aPTT but not PT. Vitamin K deficiency (choice D) impairs the synthesis of clotting factors, leading to prolonged PT but not aPTT and low levels of factors II, VII, IX, and X.
Which of the following situations will the nurse consider as risks factors for complicated grief?
- A. Childbirth, marriage and divorce
- B. Death of a spouse, child, death by suicide
- C. Inadequate perception of the grieving process
- D. Inadequate support and old age
Correct Answer: B
Rationale: The correct answer is B because the death of a spouse, child, or death by suicide are all significant losses that can lead to complicated grief due to the intensity of emotions and the disruption of daily life. These experiences can result in prolonged and severe grieving processes that may require professional intervention.
Explanation for other choices:
A: Childbirth, marriage, and divorce are not typically considered risk factors for complicated grief as they are more commonly associated with expected life events that may involve grief but not necessarily lead to complicated grief.
C: Inadequate perception of the grieving process may contribute to difficulties in coping with grief but is not a direct risk factor for complicated grief.
D: While inadequate support can impact the grieving process, and old age may present unique challenges, they are not specific risk factors for complicated grief compared to the profound loss experienced in choice B.
A patient presents with pruritic, erythematous patches with silvery scales on the elbows, knees, and scalp. Which of the following conditions is most likely responsible for this presentation?
- A. Eczema
- B. Psoriasis
- C. Pityriasis rosea
- D. Seborrheic dermatitis
Correct Answer: B
Rationale: The correct answer is B: Psoriasis. Psoriasis is characterized by pruritic, erythematous patches with silvery scales, commonly found on the elbows, knees, and scalp. This presentation matches the patient's symptoms. Eczema (choice A) typically presents with red, inflamed, and itchy skin patches. Pityriasis rosea (choice C) manifests as a herald patch followed by smaller scaly patches in a "Christmas tree" distribution. Seborrheic dermatitis (choice D) involves oily, yellowish, scaly patches mainly on the scalp, face, and ears, and does not typically present with silvery scales.