Nokea
The mother asks why she has a gush of blood coming out from the vagina that occurs when she first arises from bed. The nurse's CORRECT response should be
- A. "Blood pools at the top of the vagina and forms clots that are passed upon rising or sitting on the toilet."
- B. "Positioning causes blood to flow out when she stands.
- C. "Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep."
- D. "Normal physiologic occurrence that results as the body attempts to eliminate excess fluids."
Correct Answer: C
Rationale: The correct response is "Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep." This phenomenon occurs due to gravity when a woman lies down, and the blood tends to pool at the top of the vagina. When she first arises from bed, the pooled blood is released, resulting in a gush of blood. This is a normal physiological process and not typically a cause for concern.
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Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. what would be the nurse's FIRST action?
- A. Give an emergency bolus of oxytocin to relaxed the uterus
- B. Discontinue the administration of the oxytocin infusion
- C. Increase the rate of client's IV infusion
- D. Ask client to turn to her left side and breathe deeply
Correct Answer: B
Rationale: Patient's uterine contractions lasting 70 seconds and occurring every 90 seconds signify hyperstimulation, which can be a serious complication associated with oxytocin administration. This may result in decreased uterine perfusion, fetal distress, and other adverse effects. The first action should be to discontinue the oxytocin infusion to prevent further complications and allow the uterus to relax. Observations and assessment should continue to monitor the patient's condition and response after discontinuing the infusion. Giving an emergency bolus of oxytocin or increasing the IV infusion rate would exacerbate the hyperstimulation, and turning the client to her left side and breathing deeply would not address the underlying issue of oxytocin-induced hyperstimulation.
. The patient with nephrotic syndrome is ordered corticosteroids. Who of the following are NOT ALLOWED in the patient's
- A. Parents with diabetes.
- B. Relatives with upper respiratory tract infection.
- C. Visitors with mild asthma.
- D. Personnel with allergy.
Correct Answer: A
Rationale: Patients with nephrotic syndrome who are ordered corticosteroids need to avoid close contact with individuals who have infections or illnesses, as corticosteroids can suppress the immune system and increase the risk of infections. Therefore, it is important to prioritize the safety and well-being of the patient by minimizing potential sources of infection. While diabetes itself does not pose a direct risk to the patient with nephrotic syndrome, individuals with diabetes may have a compromised immune system or be at higher risk for infections, which could potentially be transmitted to the patient. This precaution helps to minimize the risk of infection and maximize the effectiveness of the treatment for nephrotic syndrome.
The electric fan now stops every now and then and continues to spark at intervals. The best thing to DO NEXT is to__________.
- A. turn off the fan immediately.
- B. call the maintenance immediately
- C. let it continue to function
- D. request for another fan as soon as possible (ASAP)
Correct Answer: A
Rationale: The best thing to do next is to turn off the fan immediately. The fact that the electric fan is stopping every now and then and sparking at intervals indicates a potential electrical issue or malfunction. This situation poses a safety hazard as it increases the risk of an electrical fire or damage to the fan. Turning off the fan immediately will help prevent any further damage or potential danger. After turning off the fan, it would be advisable to call for maintenance to inspect and repair the fan to ensure it is safe to use again.
A patient presents with progressive hearing loss, tinnitus, and vertigo. Audiometric testing reveals sensorineural hearing loss with a "carrot-shaped" configuration. Which of the following conditions is most likely responsible for this presentation?
- A. Presbycusis
- B. Noise-induced hearing loss
- C. Ménière's disease
- D. Acoustic neuroma
Correct Answer: C
Rationale: Ménière's disease is characterized by the triad of symptoms including progressive sensorineural hearing loss, tinnitus, and vertigo. The audiometric testing in Ménière's disease often shows a "carrot-shaped" configuration, which refers to low-frequency hearing loss initially and eventually spreading to involve higher frequencies. This distinctive pattern of hearing loss helps differentiate Ménière's disease from other causes like Presbycusis (age-related hearing loss) or Noise-induced hearing loss. Acoustic neuroma can present with unilateral sensorineural hearing loss but typically does not exhibit the specific "carrot-shaped" configuration seen in Ménière's disease.
Bleeding is the most serious complication of Dengue infection. When is the patient be watched for symptoms of bleeding?
- A. 4 th to 7 days
- B. 2nd to 3rd day
- C. At the onset of symptoms
- D. 1St day
Correct Answer: A
Rationale: Bleeding is the most serious complication of Dengue infection, typically occurring between the 4th to 7th day after the onset of symptoms. This is known as the critical phase of Dengue fever, where the patient is at a higher risk of developing severe symptoms such as bleeding manifestations. Monitoring for symptoms of bleeding during this period is crucial for timely intervention and proper management to prevent further complications or fatalities. While bleeding can occur outside this timeframe in some cases, the 4th to 7th day window is when the risk is highest and vigilance is most needed.