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Which of the following interventions is appropriate for managing a conscious patient with a severe nosebleed (epistaxis)?
- A. Tilting the head back.
- B. Pinching the soft part of the nose.
- C. Packing the nose with cotton gauze.
- D. Applying direct pressure to the forehead.
Correct Answer: B
Rationale: When managing a conscious patient with a severe nosebleed (epistaxis), the appropriate intervention is to have the patient sit upright and lean slightly forward to prevent blood from flowing into the throat and causing choking or swallowing. Pinching the soft part of the nose just below the bony part can help apply pressure to the bleeding vessel and stop the bleeding. This maneuver also helps compress the blood vessels in the nose, promoting clot formation and stopping the bleeding. It is important not to tilt the head back as this can cause blood to flow into the throat and potentially lead to swallowing, choking, or aspiration. Packing the nose with cotton gauze should be done by medical professionals if the bleeding does not stop with direct pressure. Applying direct pressure to the forehead is not effective for managing nosebleeds; pressure should be applied to the nostrils instead.
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A patient with a history of type 2 diabetes mellitus is prescribed metformin therapy. Which adverse effect is associated with metformin use and requires immediate medical attention?
- A. Hypoglycemia
- B. Lactic acidosis
- C. Hyperkalemia
- D. Peripheral neuropathy
Correct Answer: B
Rationale: Metformin is a commonly prescribed medication for the treatment of type 2 diabetes mellitus. One of the rare but serious adverse effects associated with metformin use is lactic acidosis. Lactic acidosis results from the buildup of lactic acid in the bloodstream, leading to symptoms such as weakness, rapid breathing, abdominal pain, and muscle pain. Lactic acidosis can be life-threatening and requires immediate medical attention. It is important for patients taking metformin to be aware of the signs and symptoms of lactic acidosis and seek immediate medical help if they experience any of these symptoms. Regular monitoring of kidney function is crucial in patients taking metformin to reduce the risk of lactic acidosis.
Which of the following conditions does the nurse explain to the patient the contributory factor that slows uterine involution?
- A. Full bladder during labor
- B. Difficult birth
- C. Prolonged labor
- D. Infection during pregnancy
Correct Answer: C
Rationale: Prolonged labor is a condition in which labor lasts for an extended period, typically more than 20 hours for first-time mothers and more than 14 hours for experienced mothers. Prolonged labor can contribute to slowing down uterine involution because the prolonged pressure and strain on the uterus can affect its ability to return to its pre-pregnancy size and position. The prolonged contractions and stretching of the uterine muscles can hinder the normal process of uterine involution, leading to a delay in the uterus shrinking back to its non-pregnant state. Additionally, prolonged labor can increase the risk of postpartum complications such as excessive bleeding and infection, which can further impact uterine involution. Therefore, it is crucial for healthcare providers to monitor labor progress closely to prevent prolonged labor and its potential effects on uterine involution.
The patient seems indecisive whether to breastfeed her baby or not. Which is the desired nursing action of Nurse Vera to help the pregnant patient make a decision on breastfeeding?
- A. Give pamphlets and books to read.
- B. Provide ample time for the patient to decide.
- C. Refer the patient to the nutrionist.
- D. Assist to identify breastfeeding goal and plan.
Correct Answer: D
Rationale: The desired nursing action to help the pregnant patient make a decision on breastfeeding is to assist in identifying a breastfeeding goal and plan. When patients are indecisive about breastfeeding, it is essential for the nurse to support them in setting specific goals and creating a plan that aligns with their values and circumstances. This approach can help the patient feel empowered and confident in their decision-making process. Providing pamphlets and books (choice A) may be helpful, but personalized assistance in identifying a breastfeeding goal and plan is more likely to address the patient's individual needs and concerns. Providing ample time for the patient to decide (choice B) is important, but guidance and support in setting a clear goal can facilitate the decision-making process. Referring the patient to a nutritionist (choice C) may be beneficial for dietary concerns but may not directly address the decision-making process regarding breastfeeding.
A patient is exposed to the hepatitis B virus (HBV) and develops immunity against future infections. Which type of immunity is primarily responsible for this protection?
- A. Passive immunity
- B. Innate immunity
- C. Humoral immunity
- D. Cell-mediated immunity
Correct Answer: C
Rationale: Humoral immunity is primarily responsible for protecting against infections by pathogens like viruses. In the case of the hepatitis B virus (HBV), the individual is exposed to the virus and develops immunity, which is typically mediated by antibodies produced by B cells. These antibodies circulate in the blood and can neutralize the virus, preventing future infections. This type of immunity is known as humoral immunity, as it involves the production of antibodies that target specific antigens, such as those present on the surface of the hepatitis B virus. In contrast, passive immunity is when antibodies are transferred from an external source, innate immunity provides immediate, non-specific defenses against pathogens, and cell-mediated immunity involves the activation of T cells to combat intracellular pathogens.
Which of the following is a common complication associated with prostatectomy for the treatment of benign prostatic hyperplasia (BPH)?
- A. Erectile dysfunction
- B. Urinary incontinence
- C. Retrograde ejaculation
- D. Urethral stricture
Correct Answer: B
Rationale: Urinary incontinence is a common complication associated with prostatectomy for the treatment of benign prostatic hyperplasia (BPH). Prostate surgery, such as a prostatectomy, can disrupt the sphincter muscle that controls the flow of urine from the bladder, leading to temporary or even long-term urinary incontinence in some patients. This usually improves over time with pelvic floor exercises and other treatment options, but it is an important consideration when discussing the potential risks and benefits of prostate surgery with patients. While erectile dysfunction and retrograde ejaculation can also be potential side effects of prostate surgery, urinary incontinence is specifically associated with issues related to bladder control following the procedure. Urethral stricture, although it can occur post prostate surgery, is less common compared to urinary incontinence.