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A postpartum client presents with signs of urinary retention, including suprapubic discomfort and inability to void. Which nursing intervention should be implemented first?
- A. Encouraging the client to drink plenty of fluids
- B. Assisting the client to a seated position on the toilet
- C. Performing intermittent catheterization as ordered
- D. Administering a diuretic medication as prescribed
Correct Answer: B
Rationale: Assisting the client to a seated position on the toilet should be implemented first. This position promotes relaxation of the pelvic floor muscles and can help facilitate urinary elimination. It is a non-invasive and least intrusive intervention compared to performing intermittent catheterization or administering diuretic medication. Encouraging the client to drink plenty of fluids is important for promoting overall urinary function, but in this case, the priority is to aid the client in attempting to void first.
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A patient presents with a thyroid nodule and signs of compression such as difficulty swallowing and breathing. Fine-needle aspiration biopsy reveals a follicular pattern and colloid-filled spaces. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hashimoto's thyroiditis
- B. Graves' disease
- C. Follicular adenoma
- D. Thyroid nodules
Correct Answer: C
Rationale: The patient's presentation of thyroid nodule with compression symptoms like difficulty swallowing and breathing, along with fine-needle aspiration biopsy showing a follicular pattern and colloid-filled spaces, is highly suggestive of a follicular adenoma. Follicular adenomas are benign thyroid tumors that can cause compression symptoms due to their growth and size, leading to pressure on surrounding structures in the neck area. The presence of colloid-filled spaces in the biopsy is characteristic of follicular adenomas.
Which of the following structures is responsible for secreting bile, which aids in the emulsification and digestion of fats?
- A. Liver
- B. Gallbladder
- C. Pancreas
- D. Spleen
Correct Answer: A
Rationale: The liver is responsible for secreting bile, which aids in the emulsification and digestion of fats. Bile is produced by the liver and is stored and concentrated in the gallbladder before being released into the small intestine to help with the breakdown of fats during the digestion process. The gallbladder functions as a storage organ for bile produced by the liver. The pancreas secretes digestive enzymes and bicarbonate to aid in the digestion process, while the spleen is mainly involved in immune function and blood storage.
A patient expresses fear of the unknown regarding an upcoming surgical procedure. What is the nurse's best response?
- A. Dismiss the patient's fear and assure them that the procedure is routine.
- B. Provide the patient with accurate information about the surgical procedure and what to expect.
- C. Ignore the patient's fear and proceed with scheduling the procedure.
- D. Tell the patient that fear of the unknown is irrational and unfounded.
Correct Answer: B
Rationale: The nurse's best response to a patient expressing fear of the unknown regarding an upcoming surgical procedure is to provide the patient with accurate information about the surgical procedure and what to expect. This approach empowers the patient with knowledge and helps alleviate anxiety by demystifying the unknown. By educating the patient about the procedure, potential risks, and postoperative care, the nurse can help the patient feel more prepared and in control of the situation. It is crucial for healthcare providers to address patient fears with compassion, understanding, and information to support the patient through the surgical process.
During surgery, the nurse notices that the patient's temperature is dropping below the normal range. What should the nurse do?
- A. Increase the ambient room temperature in the operating room
- B. Administer a warming blanket or forced-air warming device
- C. Document the temperature trend in the patient's chart
- D. Continue monitoring the patient's temperature closely
Correct Answer: B
Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.
Which of the following conditions is characterized by an abnormal enlargement of the prostate gland, leading to lower urinary tract symptoms such as urinary hesitancy, weak urinary stream, and incomplete bladder emptying?
- A. Prostate cancer
- B. Benign prostatic hyperplasia (BPH)
- C. Prostatitis
- D. Prostate adenoma
Correct Answer: B
Rationale: Benign prostatic hyperplasia (BPH) is a condition characterized by an abnormal enlargement of the prostate gland, which is non-cancerous. This enlargement can lead to lower urinary tract symptoms such as urinary hesitancy (difficulty starting the urine stream), weak urinary stream, incomplete bladder emptying, frequent urination, urgency, and nocturia. BPH is a common condition in aging men and is not usually associated with prostate cancer. Other conditions like prostate cancer, prostatitis, and prostate adenoma may present with similar symptoms, but BPH is specifically characterized by the non-cancerous enlargement of the prostate gland. Treatment for BPH may include medications to improve symptoms or surgical procedures to reduce the size of the prostate gland.