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A postpartum client presents with persistent, severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Notifying the healthcare provider immediately
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The presentation of persistent, severe headache, visual disturbances, and epigastric pain in a postpartum client could indicate the development of postpartum preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Prompt notification of the healthcare provider is essential to ensure timely assessment, diagnosis, and treatment to prevent potential complications for both the mother and baby. Encouraging rest, providing acetaminophen, or offering a massage are not appropriate interventions for addressing these symptoms, as they do not address the underlying cause and urgency of the situation.
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A patient presents with sudden-onset, severe eye pain, headache, nausea, and vomiting. On examination, the affected eye appears red, with a steamy cornea and mid-dilated, non-reactive pupil. Which of the following conditions is most likely responsible for this presentation?
- A. Acute angle-closure glaucoma
- B. Central retinal artery occlusion
- C. Optic neuritis
- D. Corneal ulcer
Correct Answer: A
Rationale: The presentation described is characteristic of acute angle-closure glaucoma. This condition typically presents with sudden-onset severe eye pain, headache, nausea, and vomiting. On examination, the affected eye may appear red due to conjunctival injection, and there may be a steamy cornea due to corneal edema. The mid-dilated, non-reactive pupil is a key finding in angle-closure glaucoma, as the iris bombe (forward movement of the peripheral iris) blocks the drainage angle, leading to increased intraocular pressure. If left untreated, acute angle-closure glaucoma can result in irreversible vision loss. Immediate intervention is crucial to lower the intraocular pressure and prevent further damage to the optic nerve. Prompt referral to an ophthalmologist for definitive treatment is necessary in cases of suspected acute angle-closure glaucoma.
During the surgical procedure, the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form. What should the nurse do?
- A. Proceed with the procedure as planned
- B. Document the discrepancy in the patient's chart
- C. Inform the surgeon and anesthesia provider immediately
- D. Request clarification from the patient and family members
Correct Answer: C
Rationale: If the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form, the immediate action should be to inform the surgeon and anesthesia provider. It is crucial to address any discrepancies before proceeding with the surgical procedure to ensure patient safety and prevent any potential errors or complications. The surgical team needs to be made aware of the issue so that they can verify the correct patient information and ensure that all necessary steps are taken to proceed safely. Communication and collaboration among the healthcare team members are essential in such situations to prevent any harm to the patient.
A patient presents with sudden onset of severe vertigo, nausea, vomiting, and nystagmus. The patient reports a recent upper respiratory tract infection. Which of the following conditions is most likely responsible for this presentation?
- A. Vestibular neuritis
- B. Benign paroxysmal positional vertigo (BPPV)
- C. Ménière's disease
- D. Acoustic neuroma
Correct Answer: A
Rationale: The sudden onset of severe vertigo, nausea, vomiting, and nystagmus in a patient with a recent upper respiratory tract infection is highly suggestive of vestibular neuritis. Vestibular neuritis is typically caused by inflammation of the vestibular nerve, often following a viral infection such as an upper respiratory tract infection. This condition presents with acute, severe, continuous vertigo without associated hearing loss. The presence of nystagmus, along with the absence of hearing loss, helps differentiate vestibular neuritis from Meniere's disease (which typically presents with episodic vertigo, hearing loss, and tinnitus) and acoustic neuroma (which presents with gradual onset of symptoms including unilateral hearing loss, tinnitus, and imbalance). Benign paroxysmal positional vertigo (BPPV) typically presents with brief episodes of vertigo triggered by specific head movements, rather than the continuous vertigo seen in this case.
A nurse is preparing to assist with a thoracentesis procedure for a patient with pleural effusion. What action should the nurse prioritize to ensure procedural safety?
- A. Administering pre-procedure antibiotics to prevent infection
- B. Ensuring the patient empties their bladder before the procedure
- C. Positioning the patient upright with arms supported on a bedside table
- D. Confirming the patient's informed consent before the procedure
Correct Answer: D
Rationale: Confirming the patient's informed consent before the procedure is the most crucial action for the nurse to prioritize to ensure procedural safety during a thoracentesis. Informed consent is a legal and ethical requirement that ensures the patient understands the purpose of the procedure, its potential risks, benefits, and alternatives. By confirming informed consent, the nurse ensures that the patient has the necessary information and has willingly agreed to undergo the procedure. This process promotes patient autonomy, prevents misunderstandings, and reduces the likelihood of legal issues related to the procedure. Additionally, verifying informed consent helps establish a foundation of trust between the healthcare team and the patient. While other actions like positioning the patient correctly and ensuring pre-procedure antibiotics may also contribute to the safety of the procedure, obtaining informed consent is the foundational step that must be prioritized.
As a nurse manager, which nursing action should do to let the staff imbibe the culture of quality at the health center?
- A. Become a role model
- B. Reprimand every now and then
- C. Frequent meetings
- D. Allow them to read books
Correct Answer: A
Rationale: As a nurse manager, the most effective way to let the staff imbibe the culture of quality at the health center is to become a role model. Leading by example is a powerful way to influence behavior and attitudes within a team. By demonstrating a commitment to quality in your own work, behavior, and decision-making, you set a positive example for your staff to follow. This proactive approach creates a culture of quality that is more likely to be embraced by the team as they see it being consistently demonstrated by their leader. This can result in improved staff morale, motivation, and overall performance in delivering quality care to patients. Additionally, being a role model fosters trust and respect among the staff, which is essential for building a strong team dynamic centered around quality healthcare delivery.