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What is the PRIORITY of care for patient diagnosed with Guillain-Barre Syndrome?
- A. Maintenance of respiratory function
- B. Prevention of decubitus
- C. Control of urinary tract infection
- D. Replacement of fluid and electrolytes
Correct Answer: A
Rationale: The priority of care for a patient diagnosed with Guillain-Barre Syndrome is the maintenance of respiratory function. Guillain-Barre Syndrome can cause paralysis, including respiratory muscles, leading to respiratory failure. Ensuring adequate ventilation and oxygenation is crucial to prevent complications such as respiratory failure and the need for mechanical ventilation. Monitoring for signs of respiratory distress, such as shortness of breath, decreased oxygen saturation, and diminished lung sounds, is essential in providing prompt intervention and support for the patient's respiratory needs. Other aspects of care, such as prevention of decubitus ulcers, control of urinary tract infections, and replacement of fluid and electrolytes, are also important but not as immediate or life-threatening as ensuring adequate respiratory function in these patients.
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In planning the care of the elderly, which should be the important consideration that Nurse Gina has to consider _____.
- A. The educational qualification
- B. Family support
- C. Activities of daily liiving
- D. Residence of the elderly
Correct Answer: B
Rationale: Family support is a crucial consideration when planning the care of the elderly. The availability of family members to provide emotional support, assistance with daily activities, and decision-making can greatly impact the overall well-being of the elderly individual. Family support can help reduce feelings of isolation, ensure that the elderly person's needs are being met, and provide a sense of security and comfort. Additionally, involving family members in the care planning process can help create a collaborative and comprehensive care approach that considers the preferences and values of the elderly person. Considering the level of family support is essential for creating a care plan that meets the unique needs and circumstances of each elderly individual.
A patient presents with grouped vesicles on an erythematous base, affecting the lips and perioral region. The patient reports a history of similar episodes triggered by sunlight exposure and stress. Which of the following conditions is most likely responsible for this presentation?
- A. Herpes simplex labialis (cold sores)
- B. Perioral dermatitis
- C. Angular cheilitis
- D. Allergic contact dermatitis
Correct Answer: A
Rationale: The patient's presentation with grouped vesicles on an erythematous base affecting the lips and perioral region, triggered by sunlight exposure and stress, is classic for herpes simplex labialis, commonly known as cold sores. Herpes simplex virus type 1 (HSV-1) is responsible for cold sores and is highly contagious. Recurrent episodes can be triggered by factors like UV exposure, stress, illness, and hormonal changes. Symptoms typically start with tingling or burning sensations before progressing to grouped vesicles that rupture, forming crusts. Treatment may involve antiviral medications to reduce the severity and duration of symptoms. Perioral dermatitis typically presents with papules and pustules around the mouth, while angular cheilitis involves fissures and inflammation at the corners of the mouth. Allergic contact dermatitis would present with erythema, pruritus, and possibly vesicles in
A woman in active labor experiences a prolonged latent phase, characterized by irregular contractions and minimal cervical dilation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Fetal malposition
- C. Maternal anxiety
- D. Fetal macrosomia
Correct Answer: A
Rationale: Maternal dehydration can lead to a prolonged latent phase in labor due to inadequate hydration affecting the progress of labor. Dehydration can cause decreased blood volume, leading to poor uterine perfusion and inefficient uterine contractions. It also contributes to reduced amniotic fluid volume and can lead to maternal exhaustion. Therefore, assessment and correction of maternal hydration status are crucial in improving labor patterns and preventing complications during labor and delivery.
Which of the following clinical findings is most consistent with a diagnosis of pneumonia?
- A. Inspiratory crackles and dullness to percussion
- B. Hemoptysis and pleuritic chest pain
- C. Clubbing of the fingers and cyanosis
- D. Decreased breath sounds and tracheal deviation
Correct Answer: A
Rationale: The clinical findings of inspiratory crackles (also known as rales) and dullness to percussion are most consistent with a diagnosis of pneumonia. Inspiratory crackles are abnormal lung sounds heard on auscultation and are typically due to the presence of fluid or mucus in the alveoli. Dullness to percussion can indicate consolidation of lung tissue, which is a common finding in pneumonia where the alveolar spaces are filled with inflammatory exudate. These findings suggest localized lung pathology and are commonly observed in patients with pneumonia. Hemoptysis and pleuritic chest pain (Choice B) are more suggestive of pulmonary embolism or pleurisy. Clubbing of the fingers and cyanosis (Choice C) are signs of chronic hypoxemia and are not specific to pneumonia. Decreased breath sounds and tracheal deviation (Choice D) are more indicative of conditions such as a pneumoth
Which diagnostic test could be useful in confirming the diagnosis of Dengue Fever?
- A. Rumpell -Leede
- B. Elisa
- C. Mantoux
- D. Widal
Correct Answer: B
Rationale: The diagnostic test that could be useful in confirming the diagnosis of Dengue Fever is the ELISA test. ELISA stands for Enzyme-Linked Immunosorbent Assay. This test detects the presence of dengue virus-specific antibodies (IgM and IgG) in the blood of an individual suspected to have dengue fever. Elevated levels of these antibodies indicate a recent or ongoing dengue virus infection. ELISA is a standard and reliable test used in diagnosing dengue fever, along with clinical symptoms and other laboratory tests.