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The APPROPRIATE nursing diagnosis to protect the patient from further injury is, which of the following?
- A. Altered mucous membrane related to chemotherapy.
- B. Interrupted family processes related to life threatening i1lness of a family member.
- C. Fatigue related to disease process.
- D. Risk for injury related to thrombocytopenia
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.
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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.
A patient presents with painless, progressive visual field loss, particularly in the peripheral vision, in both eyes. Gonioscopy reveals an open iridocorneal angle. Which of the following conditions is most likely responsible for this presentation?
- A. Open-angle glaucoma
- B. Closed-angle glaucoma
- C. Age-related macular degeneration
- D. Diabetic retinopathy
Correct Answer: A
Rationale: The presentation of painless, progressive visual field loss, especially in the peripheral vision, along with an open iridocorneal angle is characteristic of open-angle glaucoma. Open-angle glaucoma is a type of glaucoma where there is no physical obstruction to the outflow of aqueous humor from the eye, but there is gradual damage to the optic nerve over time. The gradual loss of peripheral vision is a common early symptom of open-angle glaucoma. It is essential to diagnose and manage open-angle glaucoma promptly to prevent irreversible vision loss.
A patient presents with fever, malaise, 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 most likely causative agent in this scenario is Borrelia burgdorferi, which is the bacterium responsible for causing Lyme disease. The classic presentation of Lyme disease includes fever, malaise, and a skin lesion resembling a "bull's eye" rash, known as erythema migrans. This rash typically appears at the site of a tick bite. If left untreated, Lyme disease can progress to involve multiple organ systems and lead to more severe complications. Plasmodium falciparum is the causative agent of malaria, which typically presents with symptoms such as fever, chills, and fatigue, but it does not cause a "bull's eye" rash. Trypanosoma cruzi is the parasite responsible for Chagas disease, which presents with symptoms such as fever, swelling at the site of entry (typically the bite wound), and enlarged lymph nodes, but it does not
This endocrine disorder is a severe form of hypothyroidism characterized by an accumulation of mucopolysaccharide in subcutaneous and other interstitial tissues
- A. Myxedema
- B. Cushing`s syndrome
- C. Thyrotoxicosis
- D. Hashimoto`s disease
Correct Answer: A
Rationale: Myxedema is a severe form of hypothyroidism that is characterized by the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues. This condition leads to puffiness, swelling, and thickening of the skin, giving it a waxy appearance. Other symptoms of myxedema include fatigue, weight gain, cold intolerance, and hair loss. It is important to recognize and treat myxedema promptly as it can lead to serious complications such as myxedema coma, which is a life-threatening condition requiring immediate medical attention.
A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?
- A. Anterior uveitis
- B. Acute angle-closure glaucoma
- C. Endophthalmitis
- D. Corneal abrasion
Correct Answer: A
Rationale: The presentation described is consistent with anterior uveitis. Anterior uveitis involves inflammation of the iris and ciliary body. Patients typically present with symptoms such as redness, pain, photophobia, and blurred vision. The slit-lamp examination findings of ciliary injection (redness and dilation of blood vessels in the iris and ciliary body), corneal edema, and a mid-dilated pupil with a fixed reaction to light (due to ciliary muscle spasm causing decreased accommodation) are characteristic of anterior uveitis. This condition is often idiopathic but can be associated with various systemic diseases like ankylosing spondylitis, inflammatory bowel disease, and other autoimmune disorders. Treatment involves addressing the inflammation with topical corticosteroids and, in some cases, cycloplegic agents to reduce pain and inflammation.