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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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A pregnant woman presents with recurrent episodes of severe abdominal pain, bloating, and constipation. On examination, an abdominal mass is palpable, and bowel sounds are diminished. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Threatened abortion
- C. Placenta previa
- D. Ovarian torsion
Correct Answer: D
Rationale: Ovarian torsion is the most likely cause of the pregnant woman's symptoms as described. Ovarian torsion occurs when the ovary twists on its pedicle, leading to compromised blood flow to the ovary. This can cause severe abdominal pain, bloating, and constipation. On examination, an abdominal mass may be palpable due to an enlarged, twisted ovary. Bowel sounds may be diminished due to the effect of the torsion on surrounding structures. Ectopic pregnancy, threatened abortion, and placenta previa are less likely to present with an abdominal mass and diminished bowel sounds.
A patient with a severe fungal infection demonstrates impaired neutrophil function. Which of the following cellular processes is most likely to be affected in this patient?
- A. Phagocytosis
- B. Antibody production
- C. Cytokine secretion
- D. Mast cell degranulation
Correct Answer: A
Rationale: Neutrophils are a type of white blood cell that play a crucial role in immune defense against pathogens, particularly in phagocytosis - the process by which they engulf and destroy invading microorganisms. In a severe fungal infection, impaired neutrophil function would most likely affect their ability to effectively perform phagocytosis, leading to a compromised immune response against the fungal pathogen. This would result in increased susceptibility to the infection and potentially severe outcomes for the patient. Antibody production, cytokine secretion, and mast cell degranulation are important components of the immune response, but neutrophils are primarily responsible for phagocytosis in the innate immune system.
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.
A patient with a history of chronic kidney disease is prescribed a low-phosphorus diet. Which dietary choice indicates understanding of the prescribed diet?
- A. Grilled chicken breast
- B. Cheese omelet
- C. Whole wheat toast with peanut butter
- D. Spinach salad with almonds
Correct Answer: A
Rationale: Grilled chicken breast is a suitable choice for a low-phosphorus diet because poultry is typically lower in phosphorus compared to dairy products (like cheese), nuts (like almonds), and whole grains (like wheat toast). This option indicates an understanding of the need to restrict phosphorus intake, which is important for individuals with chronic kidney disease to prevent complications.
The positive practice environment PPE is part of the quality standards of every health facility in the country today. Which of the following is NOT a component of the PPE in the work setting?
- A. waste management
- B. electrical wires
- C. peer review
- D. infection control
Correct Answer: B
Rationale: The positive practice environment (PPE) in a health care setting typically includes components such as waste management, infection control, and peer review. However, electrical wires are not a standard component of the PPE in a work setting. Electrical safety is important in a healthcare facility, but it is usually addressed in a separate set of guidelines and protocols focusing specifically on electrical safety and maintenance. Therefore, among the given options, electrical wires are not considered a component of the positive practice environment in the work setting.