Nokea
Nurse Mauve should plan to initiate which action to provide a safe environment?
- A. Take the patient's vital signs every 4 hours.
- B. Encourage visits from family and friends for psychosocial support.
- C. Maintain fluid and sodium restrictions.
- D. Take off the room lights and draw the window shades.
Correct Answer: D
Rationale: Taking off the room lights and drawing the window shades would provide a calm and soothing environment for the five-year-old patient admitted due to pneumonia with symptoms of cough, respiratory distress, anxiety, and dehydration. By creating a dim and quiet atmosphere, it can help reduce the child's anxiety levels, promote rest and relaxation, and potentially aid in the management of distress caused by pneumonia. Providing a quiet and dark environment can also support the child's comfort and recovery process during the hospital stay.
You may also like to solve these questions
A patient presents with severe headache, blurred vision, and fatigue. Laboratory tests reveal elevated white blood cell count, thrombocytosis, and presence of JAK2 V617F mutation. Which of the following conditions is most likely to cause these findings?
- A. Polycythemia vera
- B. Essential thrombocythemia
- C. Chronic myeloid leukemia (CML)
- D. Myelofibrosis
Correct Answer: B
Rationale: The patient's presentation of severe headache, blurred vision, and fatigue, along with the laboratory findings of elevated white blood cell count, thrombocytosis, and JAK2 V617F mutation, are characteristic of essential thrombocythemia. This is a myeloproliferative neoplasm characterized by the clonal proliferation of megakaryocytes, leading to an increased platelet count. The JAK2 V617F mutation is commonly found in essential thrombocythemia and other myeloproliferative disorders. The symptoms of essential thrombocythemia can be related to the increased blood viscosity and risk of thrombosis due to the elevated platelet count. Polycythemia vera would present with elevated red blood cell count, hemoglobin, and hematocrit, along with other features such as pruritus after a hot bath. Chronic myeloid leukemia (CML
Amy, a multiparous patient, 28 hours after Ceasarian delivery (CS), who is breastfeeding, complains of severe abdominal cramps. Nurse Kayla explains that these are caused by which of the following?
- A. Flatulence accumulation after CS
- B. Release of Oxytocin during the breastfeeding session
- C. Healing of the abdominal incision after CS
- D. Side effects of the medications administered after delivery
Correct Answer: B
Rationale: The severe abdominal cramps experienced by the multiparous patient Amy, 28 hours after a Cesarean delivery (CS) and while breastfeeding, are likely caused by the release of Oxytocin during the breastfeeding session. Oxytocin is a hormone that is naturally produced during breastfeeding to stimulate the contraction of the uterus and help reduce postpartum bleeding. These contractions may result in cramping sensations in the abdomen, specifically at the site of the uterus. It is a normal physiological response and an indication that the body is working as it should to support the postpartum recovery process.
A patient presents with a Colles' fracture. What is the characteristic deformity associated with this type of fracture?
- A. Dorsal displacement of the distal fragment
- B. Ventral displacement of the distal fragment
- C. Lateral displacement of the distal fragment
- D. Medial displacement of the distal fragment
Correct Answer: A
Rationale: Colles' fracture is a type of distal radius fracture characterized by a break of the radius bone in the forearm close to the wrist. In a Colles' fracture, the distal fragment of the fractured radius bone gets displaced dorsally, meaning it shifts upwards towards the back of the hand, creating a characteristic "dinner fork" deformity when viewed from the side. This dorsal displacement results in a visible bump on the back of the wrist and a noticeable deformity when compared to the uninjured side.
Her diagnosis of obsessive-compulsive disorder constantly does repetitive cleaning. The nurse knows that this behavior is probably MOST basically, an attempt to _______.
- A. Decrease the anxiety to a tolerable level
- B. Focus attention on non-threatening tasks
- C. Control others
- D. Decrease time available for interaction with people
Correct Answer: A
Rationale: The behavior of repetitive cleaning in someone diagnosed with obsessive-compulsive disorder is likely an attempt to decrease the anxiety to a tolerable level. People with OCD often engage in compulsive behaviors, such as cleaning, in an effort to alleviate the distress and anxiety caused by obsessive thoughts. This repetitive action provides a sense of control and temporary relief from the anxiety associated with their obsessive thoughts. By engaging in cleaning rituals, individuals with OCD can try to reduce their anxious feelings and create a sense of order and cleanliness in their environment.
A patient presents with recurrent episodes of severe headache associated with ipsilateral lacrimation, rhinorrhea, and ptosis. Symptoms are often triggered by alcohol consumption. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Migraine headache
- B. Cluster headache
- C. Tension-type headache
- D. Trigeminal neuralgia
Correct Answer: B
Rationale: The patient is presenting with symptoms consistent with cluster headache. Cluster headaches are characterized by recurrent episodes of severe unilateral (ipsilateral) headache accompanied by lacrimation (tearing from the eyes), rhinorrhea (runny nose), and ptosis (drooping of the eyelid). These headaches often occur in clusters over a period of weeks to months, hence the name "cluster headache."