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Which of the following actions is a violation of a psychiatric patient's rights?
- A. Paranoid patient with delusions about his family is told that if he makes a will, it might not be valid.
- B. The nurse confiscated the cellphone from patient's room and tell him it is being locked in the vault.
- C. Staff members confiscated written letters done by patients addressed to local newspaper.
- D. Patient is paid minimum wage for helping in the hospital kitchen.
Correct Answer: C
Rationale: In this scenario, the action that violates a psychiatric patient's rights is option C, where staff members confiscated written letters done by patients addressed to the local newspaper. Patients have the right to communicate freely and express their thoughts and feelings through various means, such as letter-writing. Confiscating these letters is a violation of their rights to free expression and communication. It is essential to respect and uphold the rights of psychiatric patients, including their right to communicate with others.
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Which of the following statements accurately describes the role of natural killer (NK) cells in the immune response?
- A. NK cells directly kill virus-infected cells and tumor cells.
- B. NK cells produce antibodies against pathogens.
- C. NK cells present antigens to T cells to initiate adaptive immunity.
- D. NK cells release cytokines to recruit other immune cells to the site of infection.
Correct Answer: A
Rationale: Natural killer (NK) cells play a vital role in the innate immune response by identifying and eliminating virus-infected cells, as well as tumor cells, without the need for prior exposure or activation. NK cells are able to detect abnormal cells by recognizing changes in the cell surface molecules, such as downregulation of MHC class I molecules. Once activated, NK cells release cytotoxic granules containing perforin and granzyme, leading to the destruction of the target cell. This direct killing mechanism is crucial for controlling viral infections and preventing the development of tumors. NK cells do not produce antibodies (option B), present antigens to T cells (option C), or release cytokines to recruit other immune cells (option D) as their primary function in the immune response.
A woman in active labor experiences frequent and intense uterine contractions with minimal rest intervals, leading to maternal fatigue and decreased fetal oxygenation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Uterine hyperstimulation
- C. Pelvic outlet obstruction
- D. Maternal exhaustion
Correct Answer: B
Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.
Which of the following conditions is characterized by chronic hypoxemia, pulmonary hypertension, and right heart failure?
- A. Chronic obstructive pulmonary disease (COPD)
- B. Idiopathic pulmonary fibrosis (IPF)
- C. Pulmonary embolism (PE)
- D. Cor pulmonale
Correct Answer: D
Rationale: Cor pulmonale is a condition characterized by right heart failure secondary to pulmonary hypertension, which is often caused by chronic hypoxemia. Chronic hypoxemia occurs in conditions such as chronic obstructive pulmonary disease (COPD) where there is limited airflow in and out of the lungs, leading to low oxygen levels in the blood. However, the specific characteristic of pulmonary hypertension leading to right heart failure distinguishes cor pulmonale from COPD. Other conditions like idiopathic pulmonary fibrosis (IPF) and pulmonary embolism (PE) may also lead to hypoxemia but are not primarily associated with pulmonary hypertension and right heart failure as in cor pulmonale.
A nurse is preparing to administer a nasogastric (NG) tube feeding for a patient. What action should the nurse prioritize before initiating tube feeding?
- A. Verifying the NG tube placement by auscultating for bowel sounds
- B. Securing the NG tube to prevent dislodgement during feeding
- C. Checking the patency of the NG tube by aspirating gastric contents
- D. Elevating the head of the bed to a semi-Fowler's position
Correct Answer: C
Rationale: The nurse should prioritize checking the patency of the NG tube by aspirating gastric contents before initiating tube feeding. This is important to ensure that the NG tube is in the correct position and that it is functioning properly. By aspirating gastric contents, the nurse can confirm that the tube is in the stomach and not in the lungs or surrounding tissues. If no gastric contents are obtained upon aspiration, it may indicate that the tube is not properly placed or may be occluded, which would require further assessment and intervention before proceeding with tube feeding. Checking the patency of the NG tube is a crucial step in ensuring the safety and effectiveness of enteral nutrition delivery.
While the nurse is taking yhe blood pressure, the patient suddenly stated."They are talking about me!". She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?
- A. Present the reality situation
- B. Distract patient's attention
- C. Disagree with the patient
- D. Validate the statement
Correct Answer: B
Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.