Nokea
Which of the ff suggestions should a nurse give breastfeeding mothers to prevent or eliminate mastitis and breast abscess? Choose all that apply
- A. Offer the opposite breast at each feeding to their
- B. Avoid frequent nursing of the infants
- C. Avoid breastfeeding
- D. Ensure that their hands and breasts are clean
Correct Answer: D
Rationale: Rationale:
D is correct because cleanliness helps prevent infections. Washing hands and keeping breasts clean reduces the risk of mastitis and abscesses.
A is incorrect because alternating breasts is a common practice in breastfeeding.
B is incorrect as frequent nursing helps maintain milk supply and prevent engorgement, reducing the risk of mastitis.
C is incorrect as breastfeeding itself is not a cause of mastitis or abscess; stopping abruptly can lead to further complications like engorgement.
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A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
- A. Decreased gastrointestinal motility
- B. Pain medication
- C. Abdominal distention
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.
. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
- A. Decreased serum sodium level
- B. Increased blood urea nitrogen
- C. Decreased serum creatinine level (BUN) level
- D. Increased hematocrit
Correct Answer: A
Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Anaphylaxis is a severe allergic reaction that can lead to airway constriction and difficulty breathing, resulting in wheezing. Wheezing is a common symptom of anaphylaxis due to bronchospasm and airway swelling. Dermatitis (A) is a skin reaction, sinusitis (B) is inflammation of the sinuses, and delirium (C) is a state of mental confusion, which are not typical symptoms of anaphylaxis. Wheezing is a critical symptom in anaphylaxis as it indicates potential airway compromise and the need for immediate medical intervention.
A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?
- A. Anemia and fatigue
- B. A noticeable lump in the neck
- C. Crackles and stridor
- D. Dysphagia or hoarseness
Correct Answer: D
Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.
Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?
- A. Incisional pain
- B. Inability to move affected leg
- C. Two-inch area of bleeding on dressing
- D. Muscle spasm of affected
Correct Answer: B
Rationale: The correct answer is B because the inability to move the affected leg post lumbar microdiskectomy could indicate a serious complication like nerve damage or blood clot. This would require immediate medical attention to prevent further complications. Incisional pain (A) is common and can be managed with pain medication. A two-inch area of bleeding on the dressing (C) is concerning but can be managed with proper wound care unless it is excessive. Muscle spasm (D) is also common postoperatively and can be managed with medications or physical therapy.