Nokea
A postpartum client who experienced a third-degree perineal laceration expresses concerns about the healing process and potential complications. What nursing intervention should be prioritized to promote optimal wound healing?
- A. Providing perineal care using peri-bottles with warm water
- B. Instructing the client on proper peri-pad application to the incision
- C. Encouraging the use of sitz baths for pain relief and wound cleansing
- D. Monitoring the incision site for signs of infection or dehiscence
Correct Answer: D
Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.
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A 38-year-old woman presents with cyclic pelvic pain, dysmenorrhea, and dyspareunia. On pelvic examination, the uterus is retroverted and fixed. Which of the following conditions is most likely to be responsible for these findings?
- A. Endometriosis
- B. Adenomyosis
- C. Leiomyomas (uterine fibroids)
- D. Pelvic inflammatory disease (PID)
Correct Answer: A
Rationale: Endometriosis is the most likely condition responsible for the symptoms described in this scenario. Endometriosis is a chronic condition in which endometrial-like tissue grows outside the uterus, commonly affecting the pelvic structures such as the ovaries, fallopian tubes, and pelvic peritoneum. The main symptoms include cyclic pelvic pain, dysmenorrhea (painful periods), and dyspareunia (pain during intercourse). The retroverted and fixed uterus on examination may be due to adhesions from endometriosis, causing the uterus to be fixed in position. Endometriosis should be considered in women of reproductive age presenting with these symptoms and pelvic examination findings.
A postpartum client who delivered twins expresses concerns about breastfeeding both infants simultaneously. What nursing intervention should be prioritized to address the client's concerns?
- A. Demonstrating tandem breastfeeding positions and techniques
- B. Recommending the use of nipple shields to facilitate latch for both infants
- C. Encouraging the client to alternate breastfeeding sessions between the infants
- D. Referring the client to a lactation consultant for assistance
Correct Answer: A
Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.
Nurse Sandy has completed the study and started to make a report to be Research department. A written brief summary is submitted which is known as _____.
- A. narrative
- B. critical appraisal
- C. abstract
- D. monograph
Correct Answer: C
Rationale: An abstract is a concise summary of a research study that provides an overview of the purpose, methods, results, and conclusions of the research. It is usually the first section of a research report or article and serves to give the reader a quick understanding of the study without having to read the full document. In this case, Nurse Sandy has completed the study and is preparing to submit a written brief summary to the Research department, which is typically in the form of an abstract. It highlights the key points of the study, allowing others to quickly grasp the main findings and implications.
A patient presents with a thyroid nodule and signs of hyperthyroidism. Fine-needle aspiration biopsy reveals spindle-shaped cells and psammoma bodies. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hashimoto's thyroiditis
- B. Graves' disease
- C. Follicular thyroid carcinoma
- D. Papillary thyroid carcinoma
Correct Answer: C
Rationale: The presence of spindle-shaped cells and psammoma bodies on fine-needle aspiration biopsy is characteristic of follicular thyroid carcinoma. This type of thyroid cancer can present as a thyroid nodule associated with signs of hyperthyroidism due to the release of thyroid hormones from the cancerous thyroid cells. Hashimoto's thyroiditis is an autoimmune condition that typically presents with hypothyroidism, while Graves' disease is another autoimmune disorder that results in hyperthyroidism but is not associated with the presence of spindle-shaped cells and psammoma bodies in this context. Papillary thyroid carcinoma may also present with thyroid nodules, but it is more commonly associated with papillary structures and nuclear features rather than spindle-shaped cells seen in follicular thyroid carcinoma.
A patient presents with acute pain, swelling, and deformity of the ankle following a twisting injury. X-ray reveals a fracture involving the distal fibula with associated widening of the ankle mortise. Which type of ankle fracture is most likely?
- A. Maisonneuve fracture
- B. Pilon fracture
- C. Tillaux fracture
- D. Trimalleolar fracture
Correct Answer: D
Rationale: A trimalleolar fracture is characterized by fractures involving the lateral malleolus (distal fibula), medial malleolus (distal tibia), and the posterior tubercle of the distal tibia. This fracture pattern results in instability of the ankle joint and is often associated with widening of the ankle mortise on X-ray. The deformity and swelling seen in this patient are indicative of a trimalleolar fracture and are typically caused by a high-energy injury, such as a forceful twisting motion. Treatment for trimalleolar fractures often involves surgical intervention to stabilize the ankle joint and restore normal function.