Nokea
What is the softening and thinning of the cervix during labor known as?
- A. Dilation
- B. Symphysis
- C. Effacement
- D. Hyperplasia
Correct Answer: C
Rationale: Effacement is the correct term for the softening and thinning of the cervix during labor. It is the process where the cervix becomes thinner, allowing it to stretch and open as labor progresses. Choice A, 'Dilation,' is incorrect as it refers to the opening of the cervix. Choice B, 'Symphysis,' is incorrect as it refers to the joint that connects the two pubic bones. Choice D, 'Hyperplasia,' is incorrect as it refers to an increase in the number of cells in an organ or tissue.
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Your client is adversely affected with fever, night sweats, occult hematuria, tenderness of the spleen, and Osler's nodes. What disorder would you most likely suspect?
- A. Tuberculosis
- B. AIDS/HIV
- C. Pericarditis
- D. Endocarditis
Correct Answer: D
Rationale: The client is likely suffering from endocarditis based on the symptoms described. Endocarditis is characterized by fever, night sweats, hematuria, splenomegaly (tenderness of the spleen), and Osler's nodes (painful nodules on the pads of the fingers or toes). While tuberculosis and AIDS/HIV can present with some similar symptoms, the presence of Osler's nodes is more specific to endocarditis. Pericarditis typically presents with chest pain, not the combination of symptoms seen in this case.
Low birth weight is defined as a newborn's weight of:
- A. 2500 grams or less at birth, regardless of gestational age.
- B. 1500 grams or less at birth, regardless of gestational age.
- C. 2500 grams or less at birth, according to gestational age.
- D. 1500 grams or less at birth, according to gestational age.
Correct Answer: A
Rationale: Low birth weight is defined as 2500 grams or less at birth, regardless of gestational age. This means that any newborn weighing 2500 grams or less is considered to have a low birth weight, irrespective of how many weeks they were in the womb. Choices B, C, and D are incorrect because they specify a weight of 1500 grams or less, which is not the standard definition of low birth weight. The correct definition is 2500 grams or less, not influenced by gestational age.
A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient?
- A. Start oxygen at 2 L/min
- B. Initiate cardiac monitoring
- C. Initiate seizure precautions
- D. Keep the patient on bed rest
Correct Answer: B
Rationale: The correct answer is to initiate cardiac monitoring. Severe hypokalemia can lead to life-threatening arrhythmias, making cardiac monitoring the priority to detect and manage any cardiac complications. Starting oxygen, seizure precautions, or bed rest are not the immediate priority actions for severe hypokalemia.
A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
- A. File an incident report.
- B. Ask the client about his injuries with the son present.
- C. Ask the client's son to go to the waiting area.
- D. Treat and discharge the client
Correct Answer: C
Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.
Which of the following healthcare providers can legally have access to all, or part, of a patient's medical record because they have a 'need to know'? Select one that does not apply.
- A. Student nurses caring for a particular patient
- B. Registered nurses when they are not caring for a particular patient
- C. The Vice President for nursing who is investigating a patient fall
- D. Licensed practical nurses caring for a particular patient
Correct Answer: B
Rationale: Student nurses, licensed practical nurses, the Vice President for nursing investigating a fall, and quality assurance nurses have a 'need to know' basis to access patient records. Registered nurses who are not directly involved in the care of a patient do not have a legitimate reason or 'need to know' to access that patient's medical records, making choice B the correct answer. The Vice President for nursing investigating a specific incident and licensed practical nurses directly involved in a patient's care have legitimate reasons to access the medical records, ensuring continuity and quality of care.