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The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action?
- A. Placing the patient in a prone position
- B. Assisting the patient into a sitting position
- C. Instilling 15 mL of warm normal saline into one of the patients ears
- D. Assessing the patients baseline hearing by performing the whisper test
Correct Answer: B
Rationale: The correct answer is B: Assisting the patient into a sitting position. The Epley maneuver is used to treat benign paroxysmal positional vertigo by repositioning displaced calcium carbonate crystals in the inner ear. This maneuver involves a series of specific head movements. Starting with the patient in a sitting position allows for proper orientation and positioning for subsequent movements to be effective. Placing the patient in a prone position (A) would not facilitate the correct positioning for the maneuver. Instilling warm saline into the ear (C) is not part of the Epley maneuver. Assessing baseline hearing (D) is unrelated to performing the Epley maneuver.
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After providing care, a nurse charts in the patient’srecord. Which entry will the nurse document?
- A. Appears restless when sitting in the chair
- B. Drank adequate amounts of water
- C. Apparently is asleep with eyes closed
- D. Skin pale and cool
Correct Answer: D
Rationale: The correct answer is D because documenting the skin condition is an objective assessment that provides vital information about the patient's health status. Pale and cool skin may indicate poor perfusion or circulation issues. This observation is crucial for monitoring the patient's condition and identifying any potential concerns. Choices A, B, and C are subjective and do not provide specific or relevant information related to the patient's overall health status or response to care. Without objective data like skin appearance, it would be challenging to assess the patient's condition accurately.
A woman calls the clinic and tells the nurse she has had bloody drainage from her right nipple. The nurse makes an appointment for this patient, expecting the physician or practitioner to order what diagnostic test on this patient?
- A. Breast ultrasound
- B. Radiography
- C. Positron emission testing (PET)
- D. Galactography Chapter 59: Male Reproductive: Terminologies PLISSIT Model, Prostate Cancer, Testicular cancer, BPH & Erectile dysfunction (ED)
Correct Answer: A
Rationale: The correct answer is A: Breast ultrasound. Bloody drainage from the nipple can be indicative of various conditions such as breast cancer. A breast ultrasound is a non-invasive imaging test that can help visualize any abnormalities in the breast tissue, including masses or tumors. It is commonly used to evaluate breast symptoms like nipple discharge. Radiography (B) is not typically used for evaluating breast conditions. Positron emission testing (PET) (C) is more commonly used in cancer staging and may not be the first-line test for this symptom. Galactography (D) is a specific imaging test used to evaluate the ducts of the breast and may not be the initial test for bloody nipple discharge.
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
A nurse is completing an OASIS data set on apatient. The nurse works in which area?
- A. Home health
- B. Intensive care unit
- C. Skilled nursing facility
- D. Long-term care facility
Correct Answer: A
Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.
A patient is learning about his new diagnosis of asthma with the asthma nurse. What medication has the ability to prevent the onset of acute asthma exacerbations?
- A. Diphenhydramine (Benadryl)
- B. Montelukast (Singulair)
- C. Albuterol sulfate (Ventolin)
- D. Epinephrine
Correct Answer: B
Rationale: The correct answer is B: Montelukast (Singulair). Montelukast is a leukotriene receptor antagonist that helps prevent asthma exacerbations by reducing inflammation in the airways. It is used as a maintenance medication to control and prevent asthma symptoms. Diphenhydramine (A) is an antihistamine used for allergies, not asthma prevention. Albuterol sulfate (C) is a rescue inhaler used for acute asthma symptoms, not prevention. Epinephrine (D) is used for severe allergic reactions (anaphylaxis), not asthma prevention.