Nokea
Patients like Emmy who have experienced delayed hypersensivity to latex FREQUENTLY complains of ______.
- A. flushing, bronchospasm
- B. urticaria, laryngeal edema
- C. rhinitis, conjunctivitis, blisters
- D. papules, vesicles, pruritus
Correct Answer: C
Rationale: Patients like Emmy who have experienced delayed hypersensitivity to latex typically present with symptoms such as rhinitis (runny or stuffy nose) and conjunctivitis (inflammation of the eyes). In addition, delayed hypersensitivity reactions often involve skin manifestations, such as blisters. These symptoms are reflective of the inflammatory response triggered by exposure to latex in individuals with delayed hypersensitivity. Symptoms like flushing, bronchospasm, urticaria, laryngeal edema, papules, vesicles, and pruritus are more commonly associated with immediate-type hypersensitivity reactions rather than delayed hypersensitivity reactions in latex-sensitive individuals.
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Which among the members of the multidisciplinary team that the nurse BEST to collaborate with when the patient can benefit the use of leg prosthesis?
- A. Occupationa l therapist
- B. Podiatrist
- C. Physical therapist
- D. Pharmacist
Correct Answer: C
Rationale: A physical therapist would be the best member of the multidisciplinary team to collaborate with when a patient can benefit from using a leg prosthesis. Physical therapists specialize in assessing and treating movement disorders, including those related to amputation and prosthetic use. They can help the patient improve their mobility, strength, balance, and overall functional abilities with the prosthesis. Physical therapists can provide training on how to use the prosthesis effectively, reduce the risk of falls, and optimize the patient's independence and quality of life. Collaborating with a physical therapist ensures that the patient receives comprehensive care tailored to their specific needs and goals related to using a leg prosthesis.
A woman in active labor presents with a prolonged latent phase, characterized by irregular and infrequent contractions. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Pelvic outlet obstruction
- C. Maternal exhaustion
- D. Fetal macrosomia
Correct Answer: A
Rationale: Maternal dehydration can contribute to a prolonged latent phase during labor. Dehydration can lead to reduced blood volume and electrolyte imbalances, which can result in ineffective uterine contractions. Without adequate hydration, the uterus may not contract effectively, causing irregular and infrequent contractions. It is important for the nurse to assess the woman's hydration status and encourage her to stay hydrated during labor to help regulate contractions and progress labor.
Case finding for PTB n the community requires that the nurse should Identify persons having sputum characterized as ________.
- A. Rusty, frothy
- B. Blood stained
- C. Yellowish
- D. Greenish
Correct Answer: B
Rationale: Identifying persons with sputum characterized as blood stained is important in case finding for pulmonary tuberculosis (PTB) in the community. Blood stained sputum, also known as hemoptysis, is a common symptom of TB. It occurs when there is bleeding in the respiratory tract, often as a result of damage to the lungs caused by tuberculosis infection. Therefore, the presence of blood in the sputum is a significant clinical finding that should alert healthcare providers, including nurses, to the possibility of TB. Early identification and diagnosis of individuals with blood stained sputum can lead to prompt treatment and the prevention of further transmission of the disease in the community.
A patient with a history of heart failure is prescribed digoxin. Which assessment finding indicates a potential adverse effect of digoxin therapy?
- A. Bradycardia
- B. Hypotension
- C. Hyperkalemia
- D. Confusion
Correct Answer: D
Rationale: Confusion is a potential adverse effect of digoxin therapy. Digoxin toxicity can manifest as various central nervous system symptoms, including confusion, delirium, and disorientation. It is important to monitor for signs of digoxin toxicity in patients taking this medication, especially those with a history of heart failure or renal impairment. Other common signs of digoxin toxicity may include visual disturbances (like halos around lights), gastrointestinal symptoms (like nausea and vomiting), and cardiac arrhythmias. Monitoring serum digoxin levels can help guide therapy and identify toxicity early.
A patient undergoing mechanical ventilation in the ICU develops ventilator-associated pneumonia (VAP) caused by methicillin-resistant Staphylococcus aureus (MRSA). What intervention should the healthcare team prioritize to manage the patient's infection?
- A. Administer vancomycin or linezolid for MRSA coverage.
- B. Perform bronchoalveolar lavage for diagnostic purposes.
- C. Implement contact precautions to prevent transmission.
- D. Recommend prophylactic antifungal therapy to prevent candidiasis.
Correct Answer: A
Rationale: The most important intervention for managing ventilator-associated pneumonia (VAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient undergoing mechanical ventilation in the ICU is to start appropriate antimicrobial therapy targeting MRSA. Vancomycin or linezolid are commonly used antibiotics for MRSA infections. These medications are effective against MRSA and can help in treating the infection and preventing further complications. It is crucial to initiate antimicrobial therapy promptly once the diagnosis of VAP caused by MRSA is suspected or confirmed to improve patient outcomes. Other interventions such as bronchoalveolar lavage for diagnostic purposes, contact precautions, or antifungal therapy may be relevant but the priority is to start effective antibiotic therapy to target the specific pathogen causing the infection.