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The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?
- A. Ask the patient when she last had anything to eat or drink.
- B. Take a culture of the lesions to verify the involved organism.
- C. Ask the patient if she has had unprotected sex since her outbreak.
- D. Use electronic fetal surveillance to determine a baseline fetal heart rate.
Correct Answer: D
Rationale: The correct answer is D: Use electronic fetal surveillance to determine a baseline fetal heart rate. This is important in assessing the well-being of the fetus during labor, especially in the presence of genital herpes lesions. Monitoring the fetal heart rate helps in detecting any signs of distress or compromise due to maternal infection.
A: Asking about the patient's last intake is important but not the immediate priority when managing a patient with active genital herpes lesions in labor.
B: Taking a culture of the lesions might be helpful but not the immediate action needed in this situation.
C: Asking about unprotected sex is relevant but not as critical as monitoring the fetal well-being during labor in this scenario.
Overall, the most critical action is to monitor the fetal heart rate for any signs of distress related to the maternal herpes infection.
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A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
- A. Position the patient in the high Fowlers position whenever possible.
- B. Temporarily eliminate animal protein from the patients diet.
- C. Make sure the patient eats at least two servings of raw fruit each day.
- D. Obtain a stool culture to identify possible pathogens.
Correct Answer: D
Rationale: The correct answer is D: Obtain a stool culture to identify possible pathogens. This is the most appropriate nursing intervention because chronic diarrhea in a patient with AIDS can be caused by various pathogens such as parasites, bacteria, or viruses. By obtaining a stool culture, the healthcare team can identify the specific pathogen responsible for the diarrhea and initiate targeted treatment.
A: Positioning the patient in the high Fowler's position is not directly related to addressing the underlying cause of chronic diarrhea in this patient.
B: Temporarily eliminating animal protein from the patient's diet may not be necessary or effective in treating chronic diarrhea without knowing the specific cause identified through stool culture.
C: Making sure the patient eats raw fruit is not recommended as raw fruits can sometimes worsen diarrhea due to their high fiber content and potential for carrying pathogens.
In summary, obtaining a stool culture is the most appropriate intervention as it helps identify the specific pathogen causing the diarrhea, while the other options do not directly address the underlying cause.
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
- A. Assess for signs and symptoms of anaphylaxis.
- B. Assess for erythema and urticaria.
- C. Administer an OTC antihistamine.
- D. Administer epinephrine.
Correct Answer: A
Rationale: The correct initial action for the school nurse is to assess for signs and symptoms of anaphylaxis (Choice A). This is crucial as anaphylaxis is a severe allergic reaction that can be life-threatening and requires immediate intervention. Assessing for anaphylaxis symptoms such as difficulty breathing, swelling of the face or throat, and a rapid pulse helps the nurse quickly identify the severity of the situation. Administering OTC antihistamines (Choice C) or epinephrine (Choice D) should only be done after confirming the presence of anaphylaxis. Assessing for erythema and urticaria (Choice B) is important but not as immediate as assessing for signs of anaphylaxis in this scenario.
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
- A. Administer antidiarrheal medications on a scheduled basis, as ordered.
- B. Encourage the patient to eat three balanced meals and a snack at bedtime.
- C. Increase the patients oral fluid intake.
- D. Encourage the patient to increase his or her activity level.
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated that he requires surgery, stating that it will leave him emasculated and a shell of a man. The nurse should identify what nursing diagnosis when planning the patients subsequent care?
- A. Disturbed Body Image Related to Effects of Surgery
- B. Spiritual Distress Related to Effects of Cancer Surgery
- C. Social Isolation Related to Effects of Surgery
- D. Risk for Loneliness Related to Change in Self-Concept
Correct Answer: A
Rationale: The correct answer is A: Disturbed Body Image Related to Effects of Surgery. This nursing diagnosis is appropriate because the patient expresses concerns about feeling emasculated and a shell of a man after the surgery, indicating a disturbance in his body image. The patient's perception of how the surgery will affect his masculinity is a clear indication of body image disturbance.
Choice B is incorrect because there is no mention of spiritual distress in the patient's statements. Choice C is incorrect as there is no indication that the patient will experience social isolation specifically related to the surgery. Choice D is incorrect as the patient's concerns are primarily related to his body image and not loneliness.
A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The patient states, They tell me my cancer is malignant, while my coworkers breast tumor was benign. I just dont understand at all. When preparing a response to this patient, the nurse should be cognizant of what characteristic that distinguishes malignant cells from benign cells of the same tissue type?
- A. Slow rate of mitosis of cancer cells
- B. Different proteins in the cell membrane
- C. Differing size of the cells
- D. Different molecular structure in the cells
Correct Answer: D
Rationale: The correct answer is D: Different molecular structure in the cells. Malignant cells have alterations in their molecular structure, leading to uncontrolled growth and invasion of surrounding tissues, while benign cells retain their normal molecular structure and do not invade nearby tissues. This distinction is crucial in understanding why malignant cells are cancerous and pose a greater risk compared to benign cells.
Other choices are incorrect because:
A: Slow rate of mitosis of cancer cells - Malignant cells actually have a rapid rate of mitosis, contributing to their uncontrolled growth.
B: Different proteins in the cell membrane - While there may be differences in proteins, the molecular structure is a more fundamental difference between malignant and benign cells.
C: Differing size of the cells - Cell size alone is not a definitive characteristic that distinguishes between malignant and benign cells; molecular structure plays a more significant role.