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The INITIAL priority assessment performed by the nurse, when admitting a patients the unit after abdominal surgery is to check for ______.
- A. surgical site for drainage and hemorrhage
- B. skin color and temperature
- C. responsiveness to painful stimuli and noise
- D. respiratory function and airway
Correct Answer: D
Rationale: When admitting a patient to the unit after abdominal surgery, the initial priority assessment performed by the nurse should focus on assessing the patient's respiratory function and airway. This is crucial because post-surgical patients are at risk for complications such as respiratory depression, atelectasis, and airway obstruction. Monitoring the patient's breathing pattern, oxygen saturation levels, and ensuring a patent airway are essential in preventing respiratory distress or failure. Prompt assessment and intervention in this area can help prevent respiratory complications and ensure the patient's safety and well-being. Once the patient's respiratory status is stable, the nurse can then proceed to assess other aspects such as the surgical site, skin color, temperature, and responsiveness to stimuli.
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A patient with a chronic viral infection demonstrates persistently elevated levels of CD8+ cytotoxic T cells in their blood. Which of the following mechanisms is most likely responsible for this observation?
- A. Activation-induced cell death (AICD)
- B. T cell exhaustion
- C. Thymic involution
- D. Antigenic variation
Correct Answer: B
Rationale: T cell exhaustion is a state of T cell dysfunction that arises during chronic viral infections or cancer. In the case of a chronic viral infection, the persistent exposure to viral antigens leads to continuous stimulation of CD8+ cytotoxic T cells. Over time, this sustained stimulation can lead to T cell exhaustion, characterized by the upregulation of inhibitory receptors, impaired effector functions, and reduced proliferative capacity. As a result, despite the elevated levels of CD8+ T cells in the blood, their function may be compromised, ultimately impacting the immune response against the viral infection. In contrast, activation-induced cell death (AICD) may contribute to T cell loss during chronic infections but would not explain the persistently elevated CD8+ T cell levels. Thymic involution refers to the age-related decline in thymus function, which is not directly related to the observed increase in CD8+ T cells. Antigenic
The CI is expected to set the atmosphere by welcoming everyone and by _________.
- A. showing every one the picture of the breast
- B. Discussing the objectives of the ward class
- C. giving an anecdote about an old man
- D. going ahead with the first part of the lecture
Correct Answer: B
Rationale: In a professional setting like a classroom or a meeting, it is important for the CI (chief instructor) to set the atmosphere by welcoming everyone and discussing the objectives of the ward class. By discussing the objectives, the CI can provide a clear direction for the session and ensure that everyone is on the same page in terms of what needs to be accomplished. This not only helps focus the participants but also creates a sense of purpose and organization, setting a positive tone for the rest of the interaction. Showing a picture of the breast or giving an anecdote about an old man may not be appropriate or relevant in this context. Going ahead with the first part of the lecture without any welcoming or setting the atmosphere may make the participants feel rushed or disconnected from the session's purpose.
A woman in active labor presents with prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Pelvic floor dysfunction
- B. Maternal fatigue
- C. Fetal macrosomia
- D. Uterine hyperstimulation
Correct Answer: A
Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.
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.
Vangie, 73 years old, comorbid with hypertension and asthma died of COVID Ariel grieved and mourned to the loss of his mother's untimely death. He is now aware that his mother is one of those 13, 425 deaths. The nurse will consider stage of grieving process is Ariel at what experiencing?
- A. Depression
- B. Denial and Anger
- C. Bargaining
- D. Acceptance
Correct Answer: A
Rationale: Ariel is likely experiencing the stage of depression in the grieving process. The stages of grief, according to the Kubler-Ross model, are denial, anger, bargaining, depression, and acceptance. In this scenario, Ariel has come to terms with his mother's death and is mourning her loss, which aligns with the stage of depression characterized by feelings of sadness, hopelessness, and intense sorrow. It is a normal part of the grieving process for individuals to experience these emotions as they process their loss.