Nokea
Pelvic ultrasound can detect, which of the following?
- A. Congenital defects in the structure, fetal gender, H-mole
- B. Fetal DM, multiple pregnancies, fetal age of gestation
- C. Fetal sex, number, and lung maturity
- D. Fetal congenital defects, placenta previa, fetal lung maturity
Correct Answer: D
Rationale: Pelvic ultrasound can detect fetal congenital defects, placenta previa, and fetal lung maturity.
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The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic manifestation for multiple myeloma does the nurse assess for?
- A. Debilitating fatigue
- B. Gradual muscle paralysis
- C. Bone pain in the back of the ribs
- D. Severe thrombocytopenia
Correct Answer: C
Rationale: Bone pain in the back of the ribs is a classic manifestation of multiple myeloma. Multiple myeloma is a type of cancer that primarily affects plasma cells in the bone marrow, leading to weakened bones and bone pain. Patients with multiple myeloma often experience bone pain in areas such as the ribs, spine, and pelvis. The bone pain is typically persistent and worsens with movement or pressure. Additionally, other common symptoms of multiple myeloma include anemia, kidney damage, recurrent infections, and elevated calcium levels in the blood.
Which of the following diagnostic tests is most appropriate for evaluating a woman with suspected cervical dysplasia?
- A. Pap smear
- B. Endometrial biopsy
- C. Colposcopy with biopsy
- D. Transvaginal ultrasound
Correct Answer: C
Rationale: Colposcopy with biopsy is the most appropriate diagnostic test for evaluating a woman with suspected cervical dysplasia. Colposcopy is a procedure in which a special magnifying instrument called a colposcope is used to examine the cervix for any abnormal areas. If abnormal tissue is identified during colposcopy, a biopsy will be taken to confirm the presence of cervical dysplasia and determine the severity. This allows for a more accurate diagnosis and appropriate management of the condition. Pap smear, although a screening test for cervical dysplasia, may not provide a definitive diagnosis and may require further evaluation with colposcopy and biopsy. Endometrial biopsy and transvaginal ultrasound are not indicated for evaluating cervical dysplasia specifically.
What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?
- A. Risk for denial
- B. Ineffective tissue perfusion
- C. Impaired gas exchange
- D. Acute pain
Correct Answer: B
Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.
Choose the step of nursing process that identiffies the famiilyy health seeking behavior.
- A. Assesment
- B. Planning
- C. Implementation
- D. Evaluation Situation
Correct Answer: A
Rationale: The step of the nursing process that identifies the family's health-seeking behavior is Assessment. During the assessment phase, the nurse gathers information about the family's health practices, beliefs, priorities, and past experiences related to seeking healthcare. This helps the nurse understand how the family approaches health and healthcare, which is crucial for providing tailored and effective care. By assessing the family's health-seeking behavior, the nurse can better collaborate with them to address their health needs and promote positive health outcomes.
A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with acute exacerbation and respiratory failure requiring mechanical ventilation. Which of the following ventilator settings is most appropriate for minimizing the risk of ventilator-induced lung injury (VILI) in this patient?
- A. Low tidal volume and high positive end-expiratory pressure (PEEP)
- B. High tidal volume and low respiratory rate
- C. Spontaneous breathing mode with pressure support ventilation (PSV)
- D. Synchronized intermittent mandatory ventilation (SIMV)
Correct Answer: A
Rationale: Patients with COPD are at increased risk for developing ventilator-induced lung injury (VILI) due to their underlying lung pathology. Using a low tidal volume strategy (6-8 ml/kg predicted body weight) has been shown to reduce the risk of VILI in these patients. Additionally, applying high positive end-expiratory pressure (PEEP) helps to recruit collapsed alveoli, improve oxygenation, and decrease the risk of barotrauma by keeping the alveoli open throughout the respiratory cycle. Therefore, the most appropriate ventilator settings to minimize the risk of VILI in a COPD patient with acute exacerbation and respiratory failure requiring mechanical ventilation would be low tidal volume and high PEEP.