Nokea
A postpartum client presents with severe abdominal pain, nausea, and vomiting. Which nursing action is most appropriate?
- A. Administering antiemetic medication as ordered
- B. Encouraging the client to drink clear fluids
- C. Assessing for signs of peritonitis or surgical abdomen
- D. Providing a heating pad to alleviate abdominal discomfort
Correct Answer: C
Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.
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Which of the following dental conditions is characterized by the wearing away of tooth structure due to friction from external sources such as toothbrushing or abrasive toothpaste?
- A. Dental caries
- B. Attrition
- C. Abrasion
- D. Erosion
Correct Answer: C
Rationale: The correct answer is C: Abrasion. Abrasion is the wearing away of tooth structure due to friction from external sources like toothbrushing or abrasive toothpaste. Dental caries (A) refers to tooth decay caused by bacteria. Attrition (B) is the wearing down of tooth structure due to tooth-to-tooth contact. Erosion (D) is the loss of tooth structure from acid attacks, not friction. Therefore, option C is the most fitting choice based on the description given.
A woman in active labor demonstrates signs of prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal fatigue
- B. Pelvic floor dysfunction
- C. Fetal macrosomia
- D. Maternal hypotension
Correct Answer: B
Rationale: When a woman in active labor exhibits signs of prolonged second stage, such as ineffective pushing efforts and slow fetal descent, one of the maternal conditions that should be considered is pelvic floor dysfunction. The pelvic floor muscles play a crucial role in supporting the uterus, bladder, and rectum. If these muscles are weak or dysfunctional, it can lead to difficulty in pushing effectively and impede the descent of the fetus through the birth canal. This can result in prolonged labor and increase the risk of complications for both the mother and the baby. Therefore, assessing for pelvic floor dysfunction is important in addressing the abnormal labor pattern and providing appropriate interventions to support the progress of labor.
Nurse Chona read in one nurse's notes chart this documentation: "Refused to eat and fell from bed". Which of the following is lacking in this documentation?
- A. Time of complaint, for missed and reaction on fall incurred.
- B. Referrals made on fall medications given and reasons of falling.
- C. Contents or complaints, reasons of refusing meal and nature of fall.
- D. Time of eating, medications for back pain and intense of pain.
Correct Answer: C
Rationale: The correct answer is C because the documentation lacks essential details regarding the contents of the complaints, reasons for refusing the meal, and the nature of the fall. This information is crucial for understanding the patient's condition and providing appropriate care. Choice A is not directly related to the documentation provided. Choice B is about referrals and medications, which are not mentioned in the documentation. Choice D is about eating time and medications for pain, which are also not relevant to the documentation provided. Therefore, the correct answer is C as it addresses the specific missing information in the nurse's notes.
A patient presents with muscle weakness and fatigue. Upon further examination, it is revealed that the patient has decreased acetylcholine receptors at the neuromuscular junction. Which of the following conditions is most likely responsible for this presentation?
- A. Myasthenia gravis
- B. Amyotrophic lateral sclerosis (ALS)
- C. Guillain-Barre syndrome
- D. Muscular dystrophy
Correct Answer: A
Rationale: The correct answer is A: Myasthenia gravis. In myasthenia gravis, there is a decrease in acetylcholine receptors at the neuromuscular junction, leading to muscle weakness and fatigue. This occurs due to autoimmune destruction of these receptors. ALS (B) affects motor neurons, not acetylcholine receptors. Guillain-Barre syndrome (C) is an autoimmune disorder affecting peripheral nerves, not neuromuscular junctions. Muscular dystrophy (D) is a genetic disorder causing muscle degeneration, not affecting acetylcholine receptors.
The nurse is working in a clinic that is designed to provide health education and immunization. As such, the clinic aims to provide_______________
- A. diagnosis and treatment
- B. Secondary prevention
- C. Primary prevention
- D. Tertiary prevention
Correct Answer: C
Rationale: The correct answer is C: Primary prevention. In this scenario, the clinic focuses on preventing disease before it occurs through health education and immunization. Primary prevention aims to promote general health and prevent the onset of diseases. It targets the entire population to reduce the risk of disease occurrence.
Incorrect Choices:
A: Diagnosis and treatment - This choice involves identifying and treating existing health conditions, which is not the primary focus of a clinic designed for health education and immunization.
B: Secondary prevention - This choice involves early detection and treatment of diseases to prevent complications, which is more focused on individuals who already have risk factors or symptoms, not on the general population.
D: Tertiary prevention - This choice involves managing and treating complications of diseases to prevent further deterioration, which is not the primary goal of a clinic focused on health education and immunization.