Nokea
Lillian asks the nurse the cause of this ailment. Which of the following would the nurse explain as predisposing factors of mastitis? (Select all that apply) I. Milk stasis II. Nipple trauma III. Using alcohol in cleaning nipples IV. Baby 's sitting position
- A. II and IV
- B. I and II
- C. I and IV
- D. II and III
Correct Answer: B
Rationale: Mastitis is typically caused by bacterial infection, with predisposing factors including milk stasis (I) and nipple trauma (II). Milk stasis occurs when milk is not effectively removed from the breast, leading to a build-up that can block ducts and predispose to infection. Nipple trauma, such as cracks or damage, can provide entry points for bacteria to infect the breast tissue. Factors like using alcohol in cleaning nipples (III) and the baby's sitting position (IV) are not directly associated with the development of mastitis.
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Which of the following actions is appropriate for managing a conscious patient with a suspected stroke?
- A. Administering aspirin immediately.
- B. Placing the patient in a supine position.
- C. Encouraging the patient to eat and drink.
- D. Activating emergency medical services (EMS) for rapid transport to a stroke center.
Correct Answer: D
Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.
Upon data collection he had been failing three times in his math class and Korino was known for substance dependent for three years. What is the MOST APPROPRIATE nursing diagnosis for him?
- A. Alteration in perception.
- B. Ineffective individual coping.
- C. Alteration in social interaction.
- D. Impaired judgment.
Correct Answer: B
Rationale: The most appropriate nursing diagnosis for the individual described is "Ineffective individual coping." This is because the individual has been facing challenges in both academic (failing math class) and personal (substance dependence) aspects of his life. The repeated failures in his math class and the substance dependence for three years indicate that he might be struggling to cope with stressors and challenges in his life effectively. By identifying this nursing diagnosis, the nurse can focus on helping the individual develop effective coping strategies to manage and overcome these difficulties.
A patient presents with fever, headache, myalgia, and a skin lesion resembling a "bull's eye" rash at the site of a tick bite. Which of the following is the most likely causative agent?
- A. Plasmodium falciparum
- B. Trypanosoma cruzi
- C. Borrelia burgdorferi
- D. Leishmania donovani
Correct Answer: C
Rationale: The presentation described in the question, including the skin lesion resembling a "bull's eye" rash at the site of a tick bite, is characteristic of Lyme disease. Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi, which is transmitted to humans through the bite of infected black-legged ticks (Ixodes scapularis). The symptoms of Lyme disease include fever, headache, myalgia, and the erythema migrans rash, which appears as a red circular rash with central clearing resembling a bull's eye.
A patient receiving palliative care for end-stage dementia experiences agitation and restlessness. What intervention should the palliative nurse prioritize to address the patient's symptoms?
- A. Administer antipsychotic medications to manage agitation.
- B. Encourage the patient to engage in physical exercise to reduce restlessness.
- C. Create a calm and soothing environment to promote relaxation.
- D. Refer the patient to a psychiatrist for evaluation and medication management.
Correct Answer: C
Rationale: The most appropriate intervention for a patient with end-stage dementia experiencing agitation and restlessness is to create a calm and soothing environment to promote relaxation. Patients with dementia often respond positively to a familiar and tranquil setting, which can help reduce their symptoms of agitation and restlessness. This approach is preferred over administering antipsychotic medications or recommending physical exercise, as these may not be feasible or beneficial for patients in the advanced stages of dementia. Referring the patient to a psychiatrist may not address the immediate need for symptom management and can be considered if other interventions are ineffective. Creating a calm environment, such as dim lighting, soft music, and familiar objects, can help provide comfort and reduce distress for the patient.
The patient record (charts) are collected every three nights from the various departments. The night nurse is EXPECTED to do the following, EXCEPT,
- A. ensure the correct order of the chart.
- B. see to the completeness of the chart pages.
- C. bind the charts as they are
- D. tape or repair torn pages
Correct Answer: C
Rationale: The night nurse is expected to collect the patient charts from various departments every three nights. Among the tasks listed, binding the charts as they are is not typically a responsibility of the night nurse. This task is usually handled by administrative staff or professional medical records technicians who are trained to manage the organization and storage of patient charts. The night nurse's primary focus should be on ensuring the correct order of the charts, checking for completeness, and addressing any issues such as torn pages by taping or repairing them to maintain the integrity of the patient records.