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A woman in active labor is diagnosed with an obstetric emergency requiring immediate delivery. What is the priority nursing action?
- A. Notifying the healthcare provider
- B. Preparing the delivery room for immediate birth
- C. Administering intravenous fluids rapidly
- D. Facilitating continuous fetal monitoring
Correct Answer: B
Rationale: In the situation of an obstetric emergency requiring immediate delivery, the priority nursing action is to prepare the delivery room for the birth. This involves ensuring that all necessary supplies and equipment are readily available, the bed is adjusted to the appropriate position, and the healthcare team is prepared to assist with the birth. By expeditiously preparing the delivery room, the healthcare team can facilitate a safe and timely delivery for both the mother and the baby. Notifications to the healthcare provider, administering intravenous fluids, and continuous fetal monitoring can be done simultaneously but preparing the delivery room takes precedence to ensure a prompt response to the emergent situation.
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Nurse Rona and her team has been utilizing the EEPIDEMIOLOGIC TRIAD model - identifying causative factors of diseases. Which of the following is not relevant this, model?
- A. External agent
- B. Treatment Regimen
- C. Susceptible host
- D. Environment
Correct Answer: B
Rationale: The Epidemiologic Triad model focuses on identifying the causative factors of diseases, particularly infectious diseases. The three components of the triad are the external agent, the susceptible host, and the environment. These factors interact to result in the occurrence of disease. Treatment Regimen, on the other hand, is not one of the causative factors but rather a response to manage and treat the disease once it has occurred. While treatment is essential, it is not part of the factors that contribute to the initial development of the disease within the Epidemiologic Triad model.
Which of the following gives cues to the nurse that the patient may be grieving for loss?
- A. Thoughts, feelings , behavior, and physiologic complaints
- B. Hallucination, panic 1evel of anxiety, sense of impending doom
- C. Sad affect, anger anxiety, and sudden change of mood
- D. Complaints of abdominal pain, diarrhea, loss of appetite
Correct Answer: A
Rationale: A grieving individual may show a range of cues across different aspects of their life. Thoughts may include constant preoccupation with the loss, difficulties in concentrating, or intrusive thoughts. Feelings may involve sadness, anger, guilt, confusion, or relief. Behavioral cues may include changes in sleep patterns, appetite, energy levels, social withdrawal, or the use of substances. Physiologic complaints can manifest as headaches, stomach issues, fatigue, or other physical symptoms. Therefore, when a nurse observes cues related to thoughts, feelings, behavior, and physiologic complaints in a patient, it can suggest that the patient is grieving for a loss.
Nurse Sandy selected a framework which focuses " that humans are in constant relationship with stressors in the environment and that nursing is keeping the patient's system adjust to wellness which is BEST reflected in _______.
- A. Parse's human becoming theory
- B. Peplau's psychodynamic theory
- C. Neuman's adaptation model
- D. Swanson's theory of caring
Correct Answer: C
Rationale: Neuman's adaptation model, also known as the Neuman Systems Model, is a nursing theory that focuses on how individuals respond to stressors in their environment. The model views individuals as being in a constant state of dynamic equilibrium, where they are interacting with stressors that can disrupt their normal functioning. Nursing care, according to this model, is aimed at helping individuals maintain or restore their optimal level of wellness by assisting them in adapting to these stressors. Therefore, Nurse Sandy's selection of a framework that emphasizes the constant relationship between humans and stressors in the environment aligns best with Neuman's adaptation model.
Which is a common verbalization of the patient with GBS regarding the EARLY ONSET of symptoms?
- A. Acute hemiplegia
- B. Ascending motor weakness
- C. Weakness of the four lower extremities
- D. Acute hemiparesis
Correct Answer: B
Rationale: Guillain-Barré Syndrome (GBS) is characterized by ascending motor weakness, starting typically in the lower extremities and progressing upwards. Patients with GBS often verbalize the early onset of symptoms as weakness starting in the legs and potentially spreading to involve the arms and sometimes the face. Therefore, the common verbalization of the patient with GBS regarding the early onset of symptoms is ascending motor weakness. Acute hemiplegia (choice A) and acute hemiparesis (choice D) involve weakness or paralysis typically limited to one side of the body, which is not a characteristic presentation of GBS. Weakness of the four lower extremities (choice C) is also not a typical description in GBS as the weakness usually starts distally and progresses proximally.
Which of the following interventions is most appropriate for a patient experiencing an acute asthma exacerbation with severe respiratory distress and hypoxemia?
- A. Administration of high-flow oxygen via nasal cannula
- B. Initiation of non-invasive positive pressure ventilation (NIPPV)
- C. Nebulized albuterol/ipratropium combination therapy
- D. Intravenous corticosteroid therapy
Correct Answer: B
Rationale: In a patient experiencing an acute asthma exacerbation with severe respiratory distress and hypoxemia, the most appropriate intervention is to initiate non-invasive positive pressure ventilation (NIPPV). NIPPV can help improve ventilation, decrease work of breathing, and correct hypoxemia by providing positive pressure to keep the airways open, reduce air trapping, and increase the elimination of carbon dioxide. This intervention can help improve oxygenation and reduce the need for invasive mechanical ventilation in patients with severe asthma exacerbations. Administering high-flow oxygen via nasal cannula alone may not provide enough support for patients with severe respiratory distress. Nebulized albuterol/ipratropium combination therapy and intravenous corticosteroid therapy are also important treatments for asthma exacerbations but are not the first-line interventions for patients with severe respiratory distress and hypoxemia.