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The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?
- A. Female fetus, Mexican-American, primigravida
- B. Male fetus, Asian-American, previous preterm birth
- C. Male fetus, African-American, previous cesarean birth
- D. Female fetus, European-American, previous spontaneous abortion
Correct Answer: C
Rationale: The correct answer is C because African-American ethnicity and previous cesarean birth are established risk factors for placenta previa due to the potential for scarring and abnormal placental implantation. Male fetus does not influence the risk. Asian-American ethnicity and previous preterm birth are not significant risk factors. European-American ethnicity and previous spontaneous abortion are also not associated with an increased risk of placenta previa.
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Which piece of data will the nurse use for “B” when using SBAR?
- A. Having chest pain
- B. Pulse rate of 108
- C. History of angina
- D. Oxygen is needed
Correct Answer: C
Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.
A 58-year-old male patient has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray shows carcinoma. The patient is anxious and asks if he can smoke. Which statement by the nurse would be most therapeutic?
- A. Smoking is the reason you are here.
- B. The doctor left orders for you not to smoke.
- C. You are anxious about the surgery. Do you see smoking as helping?
- D. Smoking is OK right now, but after your surgery it is contraindicated.
Correct Answer: C
Rationale: The correct answer is C: "You are anxious about the surgery. Do you see smoking as helping?" This response acknowledges the patient's anxiety and invites him to explore his reasons for wanting to smoke, opening up a dialogue and potentially uncovering underlying issues. It also avoids judgment or direct orders, fostering a therapeutic nurse-patient relationship.
Explanation of why the other choices are incorrect:
A: "Smoking is the reason you are here." - This response is blaming and may increase the patient's guilt or anxiety, hindering effective communication.
B: "The doctor left orders for you not to smoke." - This response is authoritative and may lead to resistance or defensiveness from the patient, rather than addressing his concerns.
D: "Smoking is OK right now, but after your surgery it is contraindicated." - This response is unclear and may send mixed messages to the patient, potentially leading to confusion or misunderstanding.
The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?
- A. Increase the rate to get the volume caught up before discontinuing.
- B. Stop the infusion as ordered.
- C. Taper infusion gradually.
- D. Hang 5% dextrose.
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Taper infusion gradually):
1. Tapering the infusion gradually allows for a smooth transition off PN without causing metabolic disturbances.
2. Abruptly stopping PN can lead to hypoglycemia and electrolyte imbalances.
3. Increasing the rate may cause fluid overload or hyperglycemia.
4. Hanging 5% dextrose alone does not provide adequate nutrition and may not meet the patient's needs.
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
- A. Antigens have bound to antibodies and formed inappropriate immune complexes.
- B. The patients body has mistakenly identified a normal constituent of the body as foreign.
- C. Sensitized T cells have caused cell and tissue damage.
- D. Mast cells have released histamines that directly cause cell lysis.
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction.
Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
The nurse notes that a patient has a history of fibroids and is aware that this term refers to a benign tumor of the uterus. What is a more appropriate term for a fibroid?
- A. Bartholins cyst
- B. Dermoid cyst
- C. Hydatidiform mole
- D. Leiomyoma
Correct Answer: D
Rationale: The correct answer is D: Leiomyoma. A leiomyoma is the medical term for a fibroid, which is a benign tumor of the uterus composed of smooth muscle tissue. This term is more appropriate as it specifically refers to fibroids.
A: Bartholins cyst is a fluid-filled swelling in the Bartholin's gland, not related to fibroids.
B: Dermoid cyst is a type of ovarian cyst containing tissues like hair, teeth, and skin, not related to fibroids.
C: Hydatidiform mole is an abnormal growth of tissue in the uterus that forms during pregnancy, not related to fibroids.