Nokea
Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?
- A. Assessment of pain level
- B. Administration of methotrexate
- C. Administration of Rh immune globulin
- D. Explanation of the common side effects of the treatment plan
Correct Answer: B
Rationale: The correct answer is B: Administration of methotrexate. This is the priority intervention for an intact tubal pregnancy to prevent further growth and potential rupture of the fallopian tube. Methotrexate is a medication used to stop the growth of the pregnancy tissue.
Assessment of pain level (A) is important but not the priority as immediate intervention to address the ectopic pregnancy is crucial.
Administration of Rh immune globulin (C) is not the priority in this situation, as it is typically given after a miscarriage or abortion to prevent Rh sensitization.
Explanation of common side effects (D) is important for patient education, but it is not the immediate priority when dealing with an ectopic pregnancy.
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Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?
- A. Rubella
- B. Cytomegalovirus (CMV)
- C. Syphilis
- D. HIV
Correct Answer: A
Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
- A. Modified radical mastectomies are very hard on a patient, both physically and emotionally and they really arent necessary anymore.
- B. According to current guidelines, having a modified radical mastectomy is no longer seen as beneficial.
- C. Modified radical mastectomies have a poor survival rate because of the risk of cancer recurrence.
- D. According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
Correct Answer: D
Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer.
2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy.
3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer.
4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal.
5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.
A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child?
- A. Handwashing can prevent the spread of the disease to others.
- B. The importance of compliance with antibiotic therapy
- C. Signs and symptoms of complications, such as meningitis and septicemia
- D. The likely need for surgery to prevent scarring of the conjunctiva
Correct Answer: A
Rationale: Step 1: Handwashing is crucial in preventing the spread of viral conjunctivitis, which is highly contagious.
Step 2: Children often touch their eyes and then surfaces, aiding in disease transmission.
Step 3: Educating parents and the child on proper hand hygiene can help contain the infection.
Step 4: Antibiotics are not effective against viral infections, so compliance is not necessary.
Step 5: Complications like meningitis and septicemia are extremely rare with viral conjunctivitis.
Step 6: Surgery is not indicated for viral conjunctivitis, as it is a self-limiting condition.
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
- A. Drink more water to prevent further dehydration.
- B. Drink more calorie-dense fluids to increase caloric intake.
- C. Drink more milk and dairy products to decrease the risk of osteoporosis.
- D. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.
Correct Answer: A
Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.
A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication?
- A. Tegretol is not known to have serious adverse effects.
- B. The patient should be monitored for bone marrow depression.
- C. Side effects of the medication include renal dysfunction.
- D. The medication should be first taken in the maximum dosage form to be effective.
Correct Answer: B
Rationale: The correct answer is B: The patient should be monitored for bone marrow depression. Carbamazepine can cause bone marrow suppression, leading to decreased production of blood cells. Monitoring blood counts is crucial to detect this adverse effect early. Choice A is incorrect as Tegretol can have serious adverse effects, including bone marrow depression. Choice C is incorrect as the main side effects of carbamazepine are related to the central nervous system, not renal dysfunction. Choice D is incorrect as medications like carbamazepine should be started at a low dose and gradually titrated up to minimize side effects.