Nokea
A patient presents with fever, chills, headache, and myalgia after returning from a camping trip. Laboratory tests reveal thrombocytopenia and leukopenia. Which of the following is the most likely causative agent?
- A. Plasmodium falciparum
- B. Trypanosoma cruzi
- C. Borrelia burgdorferi
- D. Leishmania donovani
Correct Answer: A
Rationale: The most likely causative agent in this scenario is Plasmodium falciparum, which is the parasite that causes malaria. The symptoms of fever, chills, headache, and myalgia following a camping trip are highly suggestive of malaria, especially if the patient has thrombocytopenia and leukopenia. Plasmodium falciparum is known to cause severe malaria with complications such as thrombocytopenia and leukopenia. The other options, Trypanosoma cruzi, Borrelia burgdorferi, and Leishmania donovani, do not typically present with all of the symptoms described and are not associated with the laboratory findings of thrombocytopenia and leukopenia.
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When documenting the procedures done, which of the following should NOT be recorded?
- A. Date
- B. Manufacturer
- C. Lot number
- D. Needle gauge
Correct Answer: B
Rationale: In documenting procedures, it is essential to record information that is relevant to the specific procedure done. Recording the date (A), lot number (C), and needle gauge (D) are critical details that provide important context and traceability for the procedure performed. The date helps to keep track of when the procedure was conducted. The lot number is essential for tracking the specific batch of materials used in the procedure. The needle gauge is important for ensuring the appropriate equipment is used for the procedure. However, recording the manufacturer (B) is not necessary for documenting the procedures as it does not directly impact the quality or traceability of the procedure itself.
A postpartum client who delivered via cesarean section expresses concerns about abdominal incision care and the prevention of wound complications. What nursing intervention should be prioritized to promote optimal incision healing?
- A. Providing education on proper incisional wound care techniques
- B. Administering prophylactic antibiotics to prevent infection
- C. Encouraging the use of abdominal binders for support and compression
- D. Instructing the client on the avoidance of heavy lifting and strenuous activity
Correct Answer: A
Rationale: Nursing intervention should prioritize providing education on proper incisional wound care techniques to promote optimal healing of the abdominal incision. This may include instructions on how to clean the incision site, signs and symptoms of infection, and when to seek medical attention. Proper wound care can help prevent complications such as infection and dehiscence, leading to better outcomes for the client. Administering prophylactic antibiotics, encouraging the use of abdominal binders, and instructing the client on activity restrictions are also important interventions, but educating the client on wound care techniques is crucial for their active participation in their recovery process.
What is the M0ST APPROPRIATE nursing diagnosis for this patient?
- A. Self-care deficit related to neuromuscular impairment.
- B. Alteration in nutritional status related to possible choking .
- C. Alteration in nutritional status related to anorexia.
- D. Alteration in urinary elimination related to sensory motor impairment.
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.
Endocrine changes often result in a bulimic patient. Which of the following would be an expected change in Sherry?
- A. Delayed Thyroid Stimulating Hormone response to Hormone Replacement Therapy
- B. Increased production of Follicle Stimulating Hormone
- C. Hypopituitarism
- D. Decreased Adrenocorticotropic Hormone in response to cortisone
Correct Answer: C
Rationale: Endocrine changes in a bulimic patient, such as Sherry, can lead to disruptions in the pituitary gland's function. Hypopituitarism refers to a disorder in which the pituitary gland does not produce one or more of its hormones adequately. This can result in hormonal imbalances and have various effects on the body's functions. In Sherry's case, developing hypopituitarism would be an expected change due to the endocrine disruptions associated with bulimia. It is important for healthcare providers to monitor and address these endocrine changes in bulimic patients to prevent further complications.
Some postpartum mothers will experience difficulty voiding because of the edema and trauma of the perineum. Which PRIORITY nursing measures stimulate the sensation of voiding?
- A. Encouraging her to void.
- B. Running water in the sink or shower.
- C. Helping the mother into the shower.
- D. providing cold tea or fluids of choice.
Correct Answer: B
Rationale: Running water in the sink or shower is a priority nursing measure to stimulate the sensation of voiding in postpartum mothers experiencing difficulty due to edema and trauma of the perineum. The sound and sight of running water can help relax the pelvic floor muscles and trigger the urge to void. This technique is commonly used in clinical practice to facilitate voiding and prevent urinary retention in postpartum women.