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Which of the following salivary glands is located superior and anterior to the ear and produces mainly serous saliva?
- A. Parotid gland
- B. Sublingual gland
- C. Submandibular gland
- D. Submaxillary gland
Correct Answer: A
Rationale: The parotid gland is the salivary gland that is located superior and anterior to the ear. It mainly produces serous saliva, which is a thin, watery fluid rich in enzymes. The other salivary glands mentioned are the sublingual gland, submandibular gland, and submaxillary gland, all of which have different locations and produce different types of saliva.
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A patient presents with sudden-onset severe scrotal pain, swelling, and erythema. Physical examination reveals a tender, swollen, and high-riding testicle. What is the most likely diagnosis?
- A. Testicular torsion
- B. Epididymitis
- C. Testicular trauma
- D. Testicular tumor
Correct Answer: A
Rationale: Given the sudden-onset severe scrotal pain, swelling, and erythema, along with the physical examination findings of a tender, swollen, and high-riding testicle, the most likely diagnosis is testicular torsion. Testicular torsion occurs when the spermatic cord twists, leading to compromised blood flow to the testicle, causing ischemia and severe pain. It is considered a surgical emergency that requires prompt diagnosis and intervention to salvage the affected testicle. Prompt surgical detorsion is necessary to prevent irreversible testicular damage. While epididymitis, testicular trauma, and testicular tumors can also present with scrotal pain and swelling, the presence of a high-riding testicle in this context is highly suggestive of testicular torsion.
One evening, Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse's INITIAL intervention?
- A. Give PRN medication.
- B. Refer patient to the physician.
- C. Assess the patency of the tubing.
- D. Re-assess the patient.
Correct Answer: C
Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.
A woman in active labor presents with a prolonged latent phase, characterized by irregular and ineffective contractions. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal hypotension
- B. Maternal anxiety
- C. Fetal macrosomia
- D. Maternal fever
Correct Answer: B
Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.
A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?
- A. Preparing for immediate cesarean section
- B. Administering intravenous oxytocin to augment contractions
- C. Assisting the mother into a hands-and-knees position
- D. Initiating cardiopulmonary resuscitation (CPR)
Correct Answer: A
Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine
Friendly but professional overtures have finally made Marlene open up her circumstances to the nurse, including their financial difficulty. What has been established at this time?
- A. Beginning of a friendship
- B. Trusting relationship with the nurse
- C. A lifelong commitment
- D. A dire need for financial help
Correct Answer: B
Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.