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Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
- A. Cardiomyopathy
- B. Mitral valve prolapse
- C. Rheumatic heart disease
- D. Congenital heart disease
Correct Answer: B
Rationale: The correct answer is B: Mitral valve prolapse. This condition is usually benign during pregnancy because the heart's workload increases, and the mitral valve is a one-way valve that prevents blood from flowing back into the left atrium. Mitral valve prolapse typically does not significantly affect the heart's ability to pump blood efficiently during pregnancy.
Rationale:
1. Cardiomyopathy (A) can worsen during pregnancy, leading to complications for both the mother and the fetus.
2. Rheumatic heart disease (C) can cause valve damage, increasing the risk of complications during pregnancy.
3. Congenital heart disease (D) varies in severity and can pose risks during pregnancy, depending on the specific condition.
Summary: Mitral valve prolapse is the correct answer as it is less likely to cause significant issues during pregnancy compared to the other options provided.
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A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?
- A. Preventing hemorrhage
- B. Ensuring the patient knows the treatment is palliative, not curative
- C. Protecting the safety of the patient, family, and staff
- D. Ensuring that the patient adheres to dietary restrictions during treatment
Correct Answer: C
Rationale: The correct answer is C: Protecting the safety of the patient, family, and staff. This is the priority when planning care for a patient undergoing radiation therapy due to the potential risks of radiation exposure to others. Ensuring safety involves implementing proper radiation safety protocols, educating the patient and family on safety measures, and providing a safe environment for all.
Choices A, B, and D are incorrect. Preventing hemorrhage is important but not the top priority during radiation therapy. Ensuring the patient understands the treatment's purpose is essential but not the immediate priority. Adherence to dietary restrictions is important for overall health but is not the primary focus when prioritizing actions for radiation therapy.
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
- A. Interrupted sleep pattern
- B. Hot flashes
- C. Epistaxis (nose bleed)
- D. Increased weight
Correct Answer: C
Rationale: The correct answer is C: Epistaxis (nose bleed). Thrombocytopenia is a condition characterized by a low platelet count, leading to impaired blood clotting and an increased risk of bleeding. Epistaxis is a common symptom of thrombocytopenia due to the lack of platelets to aid in clot formation. Assessing for epistaxis in patients receiving carmustine is crucial to monitor and manage potential bleeding complications. Choices A, B, and D are incorrect as they are not directly associated with thrombocytopenia.
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?
- A. Drowsiness
- B. Urinary output of 20 mL/hour
- C. Normal deep tendon reflexes
- D. Respiratory rate of 10 to 12 breaths per minute
Correct Answer: C
Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.
A nurse exchanges information with the oncomingnurse about a patient’s care. Which action did the nurse complete?
- A. A verbal report
- B. An electronic record entry
- C. A referral
- D. An acuity rating
Correct Answer: A
Rationale: The correct answer is A: A verbal report. This is because exchanging information verbally between nurses allows for real-time communication, ensuring important details are accurately conveyed. Electronic record entry (B) involves documenting information in the patient's record but does not involve direct communication. Referral (C) refers to transferring the patient's care to another healthcare provider. Acuity rating (D) is a tool used to determine the severity of a patient's condition and does not involve exchanging information between nurses.
A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patients complaint?
- A. These pains are an expected finding during the first few weeks of recovery.
- B. The patients complaints are suggestive of a postoperative infection.
- C. The patient may have experienced a spontaneous rupture of the tympanic membrane.
- D. The patients surgery may have been unsuccessful.
Correct Answer: A
Rationale: The correct answer is A. Postoperative day 6 following tympanoplasty and mastoidectomy is still within the early phase of recovery, where occasional sharp, shooting pains in the affected ear can be expected due to the healing process. Here's a step-by-step rationale:
1. Timing: It is only day 6 post-surgery, so it is normal to experience some pain as part of the healing process.
2. Nature of pain: Sharp, shooting pains are common post-surgery due to tissue healing and nerve regeneration.
3. Lack of other symptoms: The patient did not report any other concerning symptoms like fever or discharge, which would be more indicative of an infection.
4. Unlikely complications: Spontaneous rupture of the tympanic membrane or unsuccessful surgery would typically present with more severe and consistent symptoms.
Summary:
- B: Unlikely as there are no other signs of infection.
- C: Unlikely as the pain is described as occasional and sharp.
- D: