Nokea
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
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The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient which teaching points? (Select all that apply.)
- A. Increase physical activity.
- B. Keep total fat intake to 10% or less.
- C. Maintain body weight in a healthy range.
- D. Choose and prepare foods with little salt.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Increasing physical activity helps in maintaining a healthy weight and overall health.
2. Regular exercise can reduce the risk of chronic diseases like heart disease and diabetes.
3. Physical activity improves mental health and overall well-being.
4. Exercise boosts immunity and helps in managing stress levels.
Summary of why other choices are incorrect:
B. Keeping total fat intake to 10% or less is a specific dietary recommendation and not a comprehensive approach to staying healthy.
C. Maintaining body weight in a healthy range is important but does not encompass all aspects of staying healthy.
D. Choosing and preparing foods with little salt is a specific dietary recommendation and does not address the importance of physical activity in staying healthy.
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
- A. Use of oral contraceptives increases the risk of ovarian cancer.
- B. Most cases of ovarian cancer are attributed to tobacco use.
- C. Most cases of ovarian cancer are considered to be random, with no obvious causation.
- D. The majority of women who get ovarian cancer have a family history of the disease.
Correct Answer: C
Rationale: Step 1: The nurse should inform the patient that most cases of ovarian cancer are considered to be random, with no obvious causation. This is the correct answer because the exact cause of ovarian cancer is not well understood, and the majority of cases are not linked to specific risk factors.
Step 2: Choice A is incorrect because the use of oral contraceptives actually decreases the risk of ovarian cancer.
Step 3: Choice B is incorrect because tobacco use is not a major risk factor for ovarian cancer. It is primarily associated with lung and other types of cancer.
Step 4: Choice D is incorrect because while a family history of ovarian cancer can increase the risk, the majority of women diagnosed with ovarian cancer do not have a family history of the disease.
A nurse is caring for a patient who has had diarrheafor the past week. Which additional assessment finding will the nurse expect?
- A. Distended abdomen
- B. Decreased skin turgor
- C. Increased energy levels
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss and dehydration, causing a decrease in skin turgor. Assessing skin turgor by gently pinching the skin on the patient's forearm is important to determine hydration status. A: Distended abdomen is more indicative of possible bowel obstruction or fluid accumulation, not specifically related to diarrhea. C: Increased energy levels are unlikely as diarrhea typically causes fatigue and weakness due to electrolyte imbalance. D: Elevated blood pressure is not a typical finding with diarrhea unless there are other underlying medical conditions.
A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurses priority response to this event?
- A. Identify the triggers that precipitated the seizure.
- B. Implement precautions to ensure the patients safety.
- C. Teach the patients family about the relationship between brain tumors and seizure activity.
- D. Ensure that the patient is housed in a private room.
Correct Answer: B
Rationale: The correct answer is B: Implement precautions to ensure the patient's safety. When a patient exhibits seizure activity for the first time, the immediate priority is to ensure the patient's safety by implementing precautions such as protecting the patient from injury during the seizure, ensuring a patent airway, and monitoring vital signs. Identifying triggers (Choice A) can be important for long-term management but is not the priority during an acute seizure. Teaching the family about the relationship between brain tumors and seizures (Choice C) can be done later but is not the immediate priority. Ensuring a private room (Choice D) is not the priority when the patient's safety during a seizure is the main concern.
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?
- A. Assess the patient for additional signs and symptoms of Kaposis sarcoma.
- B. Review the patients most recent viral load and CD4+ count.
- C. Place the patient on respiratory isolation and inform the physician.
- D. Perform oral suctioning to reduce the patients risk for aspiration.
Correct Answer: C
Rationale: The correct answer is C: Place the patient on respiratory isolation and inform the physician. This is the most appropriate action because the patient is exhibiting symptoms that could be indicative of a potentially infectious respiratory condition, such as tuberculosis or pneumonia. Placing the patient on respiratory isolation helps prevent the spread of infection to others and protects healthcare workers. Informing the physician promptly allows for further evaluation and appropriate treatment.
Choice A is incorrect as Kaposi's sarcoma typically presents with skin lesions rather than respiratory symptoms. Choice B is incorrect as reviewing viral load and CD4+ count would not address the immediate concern of respiratory symptoms. Choice D is incorrect as oral suctioning is not the appropriate intervention for night sweats and coughing up blood.