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What PRIORITY nursing action should you do with the presenting clinical manifestations of the patient?
- A. Report to the physician status of the patient at once.
- B. Take Blood pressure and respiratory rate.
- C. Stop temporarily the Tota l Parenteral Nutrition
- D. Administer Oxygen inhalation.
Correct Answer: D
Rationale: Administering oxygen inhalation is the priority nursing action for a patient presenting with clinical manifestations related to endocrine disorders. Patients with hyperthyroidism, Cushing syndrome, and hypothyroidism can all experience respiratory distress due to various reasons such as thyroid storm, adrenal crisis, or myxedema coma. Oxygen inhalation helps improve oxygenation and tissue perfusion, providing immediate support to the patient's respiratory system. It is crucial to ensure adequate oxygenation before addressing other assessments or interventions. Once the patient's breathing is stabilized, further assessments and treatments can be initiated as necessary.
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In order to determine the patient's ability to concentrate and focus, which would be the PRIORITY nursing action?
- A. Asked for the academic performance
- B. Conduct paper and pencil test
- C. Assess the mental status of the patient
- D. Refer the patient to the psychiatrist
Correct Answer: C
Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.
Identify the MOST appropriate diagnostic examination that confirms the iincidence of hypertension amongg residents.
- A. Chest xray
- B. Ultrasound
- C. Electrocardiogram
- D. BP monitoring
Correct Answer: D
Rationale: The most appropriate diagnostic examination to confirm the incidence of hypertension among residents is blood pressure (BP) monitoring. Hypertension is defined by elevated blood pressure readings consistently measured over time. Monitoring of blood pressure is essential for diagnosing hypertension and determining the severity of the condition. Chest x-ray, ultrasound, and electrocardiogram are not specific tests for diagnosing hypertension. While these tests may be useful in assessing potential complications or causes of hypertension, they do not directly confirm the presence of high blood pressure. Regular BP monitoring with the use of a sphygmomanometer or automated blood pressure device is crucial in diagnosing and managing hypertension.
A patient presents with watery diarrhea, abdominal cramps, and nausea after consuming contaminated water from a stream during a camping trip. Laboratory tests reveal oocysts in the stool sample. Which of the following parasites is most likely responsible for this infection?
- A. Giardia lamblia
- B. Entamoeba histolytica
- C. Cryptosporidium parvum
- D. Cyclospora cayetanensis
Correct Answer: C
Rationale: Cryptosporidium parvum is a protozoan parasite often found in contaminated water sources. This parasite is known to cause watery diarrhea, abdominal cramps, and nausea in infected individuals. The presence of oocysts in the stool sample is characteristic of Cryptosporidium infection. Other parasitic infections may present with similar symptoms, but in this case, the most likely culprit based on the exposure history and laboratory findings is Cryptosporidium parvum.
A patient with chronic respiratory failure secondary to severe restrictive lung disease requires long-term oxygen therapy to maintain adequate oxygenation. Which of the following oxygen delivery devices is most appropriate for delivering continuous supplemental oxygen in this patient?
- A. Nasal cannula
- B. Venturi mask
- C. Partial rebreather mask
- D. Non-rebreather mask
Correct Answer: D
Rationale: The most appropriate oxygen delivery device for a patient with chronic respiratory failure secondary to severe restrictive lung disease requiring continuous supplemental oxygen is a non-rebreather mask. A non-rebreather mask is designed to deliver high-flow oxygen and is typically used for short-term medical treatment in emergency situations or for critically ill patients. It is ideal for providing the highest concentration of oxygen available for inhalation, making it suitable for patients with severe hypoxemia.
A patient in the ICU develops catheter-related bloodstream infection (CRBSI) associated with a central venous catheter. What intervention should the healthcare team prioritize to manage the patient's infection?
- A. Remove the central venous catheter to eliminate the source of infection.
- B. Administer broad-spectrum antibiotics targeting common pathogens.
- C. Perform blood cultures to identify the causative organism.
- D. Implement sterile dressing changes and catheter care protocols.
Correct Answer: A
Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.