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Jane Love, a 35-year-old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?
- A. anemia
- B. edema
- C. painless vaginal bleeding
- D. fatigue
Correct Answer: C
Rationale: Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright red, painless bleeding. While anemia (choice A) may be a consequence of chronic bleeding from placenta previa, it is not a direct indicator. Edema (choice B) and fatigue (choice D) are nonspecific symptoms that can occur in pregnancy but are not specific to placenta previa.
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A healthcare professional is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?
- A. Horizontal
- B. Sagittal
- C. Frontal
- D. Vertical
Correct Answer: B
Rationale: The correct answer is 'Sagittal.' The sagittal plane divides the body into left and right halves, and movements in this plane involve flexion and extension. In this case, limited shoulder flexion on the left indicates a restriction in the forward and backward movement of the arm, which occurs in the sagittal plane. Choice A, 'Horizontal,' is incorrect as it refers to movements parallel to the ground. Choice C, 'Frontal,' is incorrect as it involves side-to-side movements. Choice D, 'Vertical,' is incorrect as it typically refers to up and down movements.
A healthcare professional is assessing a patient in the rehab unit during shift change. The patient has sustained a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short-term memory
- C. Babinski sign
- D. Clonus sign
Correct Answer: A
Rationale: Level of consciousness (LOC) is the most crucial indicator of impaired neurological function. Changes in LOC can signify various neurological conditions, including traumatic brain injury. Short-term memory, while important, is not the most distinguishing characteristic of neurological disturbances. Babinski and Clonus signs are specific neurological tests that can provide information about upper motor neuron lesions but are not as generalizable as changes in LOC for assessing overall neurological status.
During a stress test, a patient complains of severe chest pain. Which of the following medications is the most appropriate to relieve this discomfort?
- A. Aspirin
- B. Diazoxide
- C. Procardia
- D. Mannitol
Correct Answer: C
Rationale: In this scenario, the most appropriate medication to relieve severe ischemic chest pain during a stress test is Procardia. Procardia, a calcium channel blocker, is effective in quickly alleviating chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Aspirin, although important for antiplatelet effects, is not the best choice for immediate relief of severe chest pain. Diazoxide is a vasodilator used in hypertensive emergencies, not for acute chest pain. Mannitol is an osmotic diuretic used to reduce intracranial pressure, not for chest pain relief.
During a screening on a patient with a recent cast on the left lower extremity, which of the following statements should the nurse be most concerned about?
- A. The patient reports, "I didn't keep my extremity elevated as the doctor asked me to."?
- B. The patient reports, "I have been having pain in my left calf."?
- C. The patient reports, "My left leg has really been itching."?
- D. The patient reports, "The arthritis in my wrists is flaring up when I put weight on my crutches."?
Correct Answer: B
Rationale: The correct answer is B because pain in the left calf could indicate a potential neurovascular complication related to the casted extremity. It could suggest issues such as compartment syndrome or impaired circulation. Option A is not as concerning since not elevating the extremity may lead to swelling but is not an immediate concern. Option C indicates itching, which is common with casts and not as concerning as potential neurovascular issues. Option D, regarding arthritis in the wrists, is unrelated to the lower extremity issue being screened for.
A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?
- A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
- B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
- C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
- D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus
Correct Answer: B
Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD).
Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest.
Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production.
Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.