Nokea
The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis?
- A. External otitis is characterized by aural tenderness.
- B. External otitis is usually accompanied by a high fever.
- C. External otitis is usually related to an upper respiratory infection.
- D. External otitis can be prevented by using cotton-tipped applicators to clean the ear.
Correct Answer: A
Rationale: External otitis, also known as swimmer's ear, is an infection of the outer ear canal. It is often characterized by aural tenderness, which means that the ear is sensitive to touch and can be painful, especially when pressure is applied to the area. This tenderness is a hallmark symptom of external otitis and helps differentiate it from other ear conditions. Other common symptoms of external otitis include ear pain, itchiness, redness, and swelling of the ear canal. External otitis is usually not accompanied by a high fever, and it is not typically related to an upper respiratory infection. Using cotton-tipped applicators to clean the ear can actually increase the risk of developing external otitis by disrupting the natural protective barrier of the ear canal.
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The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?
- A. Washing his face
- B. Exposing his skin to sunlight
- C. Using artificial tears
- D. Drinking large amounts of fluids
Correct Answer: A
Rationale: Trigeminal neuralgia is a condition characterized by severe facial pain due to irritation or damage to the trigeminal nerve. Factors such as touching or lightly brushing the face, chewing, speaking, or even encountering a breeze can trigger an attack. Therefore, activities like washing the face that involve touching or stimulating the trigeminal nerve can precipitate an attack in patients with trigeminal neuralgia. It is important for patients to be aware of these triggers to help manage and prevent episodes of pain.
A patient with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the patient is questioned, she relates that there is history of heart disease in her family; but, that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the patient is discharged. The patient returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension is the patient is exhibiting?
- A. Pregnancy-induced hypertension (PIH)
- B. Gestational hypertension
- C. Preeclampsia superimposed on chronic hypertension
- D. Undiagnosed chronic hypertension
Correct Answer: D
Rationale: The patient in this scenario exhibits signs of chronic hypertension, particularly due to the history of heart disease in her family, the postpartum persistence of elevated blood pressure, and the diagnosis of hypertension at the 6-week checkup. While pregnancy-induced hypertension (PIH), gestational hypertension, and preeclampsia can occur during pregnancy, they typically resolve within a few weeks after delivery. The fact that the patient's hypertension persists beyond the postpartum period suggests that she likely had preexisting, undiagnosed chronic hypertension. Therefore, option D is the most appropriate choice in this case.
The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to
- A. monitor uterine contractions.
- B. assess fetal heart rate and maternal vital signs.
- C. place clean disposable pads to collect any drainage.
- D. perform a venipuncture for hemoglobin and hematocrit levels.
Correct Answer: B
Rationale: When admitting a pregnant patient who has experienced a bleeding episode in late pregnancy, the top priority nursing intervention is to assess fetal heart rate (FHR) and maternal vital signs. This assessment will help the nurse determine the extent of the blood loss and its impact on both the mother and the fetus. Monitoring uterine contractions is important as well, but not the priority in this situation. Placing clean disposable pads to collect any drainage is important for ongoing assessment and management but can be done after assessing the FHR and vital signs. Performing a venipuncture for hemoglobin and hematocrit levels is necessary for further evaluation but can be done after the initial assessment of FHR and vital signs. Checking the patient and fetal well-being is crucial in situations of bleeding in late pregnancy to ensure timely and appropriate intervention.
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?
- A. To promote autonomy
- B. To use common courtesy
- C. To establish trustworthiness
- D. To standardize communication
Correct Answer: D
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.
A female patient tells the nurse that she thinks she has a vaginal infection because she has noted inflammation of her vulva and the presence of a frothy, yellow-green discharge. The nurse recognizes that the clinical manifestations described are typical of what vaginal infection?
- A. Trichomonas vaginalis
- B. Candidiasis
- C. Gardnerella
- D. Gonorrhea
Correct Answer: A
Rationale: The clinical manifestations of inflammation of the vulva and the presence of frothy, yellow-green discharge are indicative of a vaginal infection caused by Trichomonas vaginalis. Trichomoniasis is a sexually transmitted infection caused by a protozoan parasite. It commonly presents with symptoms such as frothy, yellow-green vaginal discharge, vaginal itching, inflammation of the vulva, and sometimes a foul odor. Testing for Trichomonas vaginalis can be done through microscopic examination of the vaginal discharge or through nucleic acid amplification tests. Treatment usually involves the use of antibiotics such as metronidazole or tinidazole. It is important to promptly diagnose and treat trichomoniasis to prevent complications and further transmission.