The false statement about physiologic jaundice in the statements below is _____
- A. Caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase.
- B. Begins to decrease by the 6th or 7th day.
- C. Is visible in skin and sclera.
- D. Begins after 48 hours of 1ife.
Correct Answer: A
Rationale: Physiologic jaundice in newborns is a common and typically benign condition caused by the immaturity of the newborn's liver. The correct statement about physiologic jaundice is that it occurs due to an imbalance between the production and elimination of bilirubin. In contrast, Option A is the false statement because it incorrectly states that physiologic jaundice is caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase. This statement is inaccurate as physiologic jaundice results from the immature liver's reduced ability to conjugate bilirubin.
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A postpartum client who delivered vaginally reports difficulty emptying the bladder completely and experiences urinary frequency. What nursing intervention should be prioritized to address this issue?
- A. Assessing for signs of urinary retention or bladder distention
- B. Encouraging the client to increase fluid intake to promote urination
- C. Recommending the use of warm compresses to the suprapubic area
- D. Teaching the client pelvic floor exercises to improve bladder control
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.
A nurse is preparing to perform a bladder catheterization for a patient with urinary retention. What action should the nurse prioritize to minimize the risk of infection?
- A. Using sterile gloves and a surgical mask during catheterization
- B. Cleansing the perineal area with povidone-iodine solution before catheter insertion
- C. Administering prophylactic antibiotics before the catheterization procedure
- D. Using aseptic technique and sterile equipment during catheter insertion
Correct Answer: D
Rationale: Using aseptic technique and sterile equipment during catheter insertion is crucial for minimizing the risk of infection during bladder catheterization. Aseptic technique involves maintaining a sterile field, washing hands thoroughly, using sterile gloves, and ensuring that all equipment used is sterile. By following these practices, the nurse can prevent introducing bacteria into the urinary tract, reducing the likelihood of infection in the patient. While cleansing the perineal area with antiseptic solutions is important for general hygiene, the priority for infection prevention during catheterization lies in maintaining a sterile environment during the procedure. Administering prophylactic antibiotics is not routinely recommended for catheterization unless there are specific risk factors present.
A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. The charge nurse appropriately identifies that nurse has committed:
- A. Defamation
- B. assault
- C. battery .
- D. fraud.
Correct Answer: C
Rationale: Battery occurs when there is an intentional touching of another person without their consent. In this case, the nurse began cardiopulintary resuscitation on a client who had requested a "Do Not Resuscitate" (DNR) order, which means the client did not consent to the resuscitation. This action can be considered as battery because the client's wishes were not respected, and the nurse proceeded with a medical intervention against those wishes, leading to harm and potential legal consequences. This is different from assault, which involves a threat of force, and from defamation and fraud, which are not applicable to this situation.
In caring for this patient suffering from anorexia nervous, which task can be delegated to the nursing assistant?
- A. Obtaining special food for the patient when she request it
- B. Sitting with the patient during meals and for about an hour after/meals
- C. Weighing the patient daily and reinforcing that she is underweight
- D. Observing for reporting ritualistic behaviors related to food
Correct Answer: A
Rationale: Task A, obtaining special food for the patient when she requests it, can be delegated to the nursing assistant. This task involves simple assistance with gathering food items and does not require specific medical knowledge or interventions. Tasks B, C, and D involve more direct patient care and assessment, which should be performed by the nursing staff who have the necessary training and expertise to address the complexities of anorexia nervosa.
A patient presents with sudden-onset severe headache, nausea, vomiting, and photophobia. On examination, there is neck stiffness and positive Kernig and Brudzinski signs. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Meningitis
- B. Subdural hematoma
- C. Intracerebral hemorrhage
- D. Acute angle-closure glaucoma
Correct Answer: A
Rationale: The symptoms described - sudden-onset severe headache, nausea, vomiting, photophobia, neck stiffness, and positive Kernig and Brudzinski signs - are classic manifestations of meningitis. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord, often caused by infection. The sudden onset of these symptoms and signs, along with neck stiffness and positive Kernig and Brudzinski signs (indicative of meningeal irritation), strongly suggest meningitis as the most likely diagnosis in this scenario.