Nokea
Ella states'I will hang my self' this is a manifestation of:
- A. Denial
- B. Suicidal intent
- C. Suicidal threat
- D. Paranoia.
Correct Answer: B
Rationale: Ella's statement "I will hang myself" directly indicates a desire and intent to commit suicide. This is classified as a suicidal intent, which is a serious concern that requires immediate attention and intervention. It is crucial to take any mention or indication of suicide seriously and seek help from mental health professionals or crisis intervention services.
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A postpartum client reports severe perineal pain and difficulty passing stools following a vaginal delivery. Which nursing intervention should be implemented?
- A. Administering a stool softener as ordered
- B. Encouraging the client to refrain from defecation until pain subsides
- C. Applying ice packs to the perineum for pain relief
- D. Providing education on proper perineal hygiene
Correct Answer: A
Rationale: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.
Which of the following cell types is primarily responsible for the production of antibodies during the humoral immune response?
- A. Plasma cells
- B. T helper cells (Th cells)
- C. Memory B cells
- D. Macrophages
Correct Answer: A
Rationale: Plasma cells are the primary type of cells responsible for the production of antibodies during the humoral immune response. When activated by antigens, B cells differentiate into plasma cells, which are specialized in producing large quantities of antibodies. These antibodies are essential in fighting off infections by binding to antigens and marking them for destruction by other immune cells. T helper cells assist in activating B cells, but the actual production of antibodies is mainly carried out by plasma cells. Memory B cells are involved in mounting a rapid and specific secondary response upon re-exposure to the same antigen. Macrophages play a role in phagocytosis and antigen presentation, but they are not the primary cells responsible for producing antibodies during the humoral immune response.
The MOST common reported abuse experienced by nurses in their workplace is
- A. Physical abuse
- B. Financial abuse
- C. Verbal abuse
- D. Sexual abuse
Correct Answer: C
Rationale: Verbal abuse is the most common form of abuse experienced by nurses in their workplace. This may include insults, yelling, threats, or intimidation directed towards the nurse. Verbal abuse can have a significant impact on the nurse's mental and emotional well-being, leading to stress, anxiety, and burnout. It is important for healthcare institutions to address and prevent verbal abuse to create a safe and respectful work environment for nurses and other healthcare professionals.
A patient is prescribed a calcium channel blocker for the management of hypertension. Which adverse effect should the nurse monitor closely in the patient?
- A. Hypoglycemia
- B. Peripheral edema
- C. Hypokalemia
- D. Tachycardia
Correct Answer: D
Rationale: Calcium channel blockers are often prescribed for the management of hypertension because they can help relax blood vessels and slow the heart rate, thus reducing blood pressure. One of the major adverse effects associated with calcium channel blockers is bradycardia (slow heart rate) or even more rarely, tachycardia (fast heart rate). Therefore, in a patient prescribed a calcium channel blocker for hypertension, the nurse should closely monitor for any signs and symptoms of tachycardia as it can be a serious adverse effect that needs prompt evaluation and intervention to prevent complications.
Which of the following statements is NOT true of Pneumothorax?
- A. Atmospheric air within the pleural space can result to a rise in intra thoracic pressure and reduces vital capacity in the lungs
- B. The loss of positive intra-pleural pressure can produce pneumothorax
- C. The loss of negative intra pleural pressure can result to collapse of the lungs.
- D. A spontaneous pneumothorax can occur with the rupture of pulmonary bleb.
Correct Answer: C
Rationale: In pneumothorax, air enters the normally negative pressure space between the lung and chest wall, leading to loss of negative intra-pleural pressure. However, this loss of negative pressure typically does not directly result in lung collapse. Instead, the accumulation of air in the pleural space can lead to a pressure imbalance, causing the lung to collapse partially or completely, which is known as atelectasis. Therefore, it is more accurate to state that the loss of negative intra-pleural pressure can result in lung collapse due to the presence of air in the pleural space, rather than the loss of negative pressure itself causing the collapse.