Nokea
The penis is associated most with which system in the human body?
- A. The skeletal system
- B. The reproductive system
- C. The circulatory system
- D. The endocrine system
Correct Answer: B
Rationale: The penis is a primary organ of the male reproductive system, involved in sexual intercourse and urination.
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The experienced nurse is instructing the new nurse about communications concerning the patient. The nurse suggests using an SBAR method and lists the four elements included in the technique. Which four elements should be included in the instruction?
- A. Shift-end report, background, assessment, and reassessment
- B. Situation, background, assessment, and recommendation
- C. Shift-end report, background, assessment, and recommendation
- D. Situation, background, actual nursing diagnoses, and remedy
Correct Answer: B
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. This method is widely used in healthcare settings to ensure clear and concise communication.
During a patient's physical examination the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as:
- A. Hegar's sign.
- B. McDonald's sign.
- C. Chadwick's sign.
- D. Goodell's sign.
Correct Answer: A
Rationale: At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment occurs; this is called Hegar's sign.
The diagnosis of pregnancy is based on which positive signs of pregnancy? (Select all that apply.)
- A. Identification of fetal heartbeat
- B. Palpation of fetal outline
- C. Visualization of the fetus
- D. Verification of fetal movement
Correct Answer: A
Rationale: Step-by-step rationale for choice A (Identification of fetal heartbeat) being correct:
1. Detection of fetal heartbeat confirms the presence of a developing fetus.
2. It is a definitive sign of pregnancy and indicates fetal viability.
3. Fetal heartbeat can be detected using ultrasound or Doppler.
4. This sign is not subject to interpretation or misinterpretation.
Summary of why the other choices are incorrect:
- Choice B (Palpation of fetal outline) and D (Verification of fetal movement) are considered probable signs of pregnancy and do not provide definitive confirmation.
- Choice C (Visualization of the fetus) is not a reliable sign as it requires advanced imaging techniques and can be subjective.
Which finding in the urine analysis of a pregnant woman is considered a variation of normal?
- A. Proteinuria
- B. Glycosuria
- C. Bacteria in the urine
- D. Ketones in the urine
Correct Answer: B
Rationale: The correct answer is B: Glycosuria. In pregnant women, glycosuria is considered a variation of normal due to the hormonal changes affecting glucose metabolism. During pregnancy, the renal threshold for glucose is lowered, leading to glucose spillage in urine without significant pathology. Proteinuria (A) can indicate kidney damage. Bacteria in the urine (C) suggest a possible urinary tract infection. Ketones in the urine (D) may indicate a metabolic disorder or inadequate carbohydrate intake. Glycosuria in pregnancy is a physiological adaptation and not necessarily a cause for concern.
A client at 26 weeks gestation is in the office after being discharged from the hospital for preterm contractions. She states that she no longer is having contractions but is really having trouble with heartburn and reflux. Which is the nurse's best response?
- A. Mix 1 teaspoon of baking soda in a glass of water and drink before eating your meal.
- B. Use a laxative when your reflux is bad and this will help to empty your stomach.
- C. Always drink plenty of fluids with your meals to help dilute the food.
- D. Avoid foods that contain a lot of fat.
Correct Answer: D
Rationale: The correct answer is D: Avoid foods that contain a lot of fat. This is the best response because fatty foods can worsen heartburn and reflux by relaxing the lower esophageal sphincter, leading to acid reflux. By avoiding high-fat foods, the client can reduce the likelihood of experiencing heartburn and reflux symptoms.
Rationale:
1. High-fat foods can delay stomach emptying, causing food to stay longer in the stomach, increasing the risk of reflux.
2. Fatty foods can trigger the production of more stomach acid, exacerbating heartburn and reflux.
3. Avoiding high-fat foods can help decrease pressure on the stomach, reducing the likelihood of acid reflux.
4. Other options (A, B, C) do not address the root cause of heartburn and reflux associated with high-fat foods.
In summary, choosing option D to avoid high-fat foods is the most appropriate response to help alleviate the client's heartburn and reflux symptoms during pregnancy.