Nokea
Which of the following statements should Nurse Cora consider as TRUE with anorexia nervosa?
- A. Thinness is equated with vanity among Peers.
- B. Eating disorders are not major health problems -
- C. Cultures linking beauty to thinness increase risk of the Illness.
- D. Anorexia nervosa is not considered as a mental disorder.
Correct Answer: C
Rationale: Nurse Cora should consider statement C as TRUE with anorexia nervosa. Cultures that portray thinness as the ideal standard of beauty can increase the risk of developing anorexia nervosa. This is because individuals may internalize these societal norms and feel pressure to attain the thin ideal, leading to disordered eating behaviors.
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A woman in active labor presents with prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Pelvic floor dysfunction
- B. Maternal fatigue
- C. Fetal macrosomia
- D. Uterine hyperstimulation
Correct Answer: A
Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.
A nurse is preparing to assist with a thoracentesis procedure for a patient with pleural effusion. What action should the nurse prioritize to ensure procedural safety?
- A. Administering pre-procedure antibiotics to prevent infection
- B. Ensuring the patient empties their bladder before the procedure
- C. Positioning the patient upright with arms supported on a bedside table
- D. Confirming the patient's informed consent before the procedure
Correct Answer: D
Rationale: Confirming the patient's informed consent before the procedure is the most crucial action for the nurse to prioritize to ensure procedural safety during a thoracentesis. Informed consent is a legal and ethical requirement that ensures the patient understands the purpose of the procedure, its potential risks, benefits, and alternatives. By confirming informed consent, the nurse ensures that the patient has the necessary information and has willingly agreed to undergo the procedure. This process promotes patient autonomy, prevents misunderstandings, and reduces the likelihood of legal issues related to the procedure. Additionally, verifying informed consent helps establish a foundation of trust between the healthcare team and the patient. While other actions like positioning the patient correctly and ensuring pre-procedure antibiotics may also contribute to the safety of the procedure, obtaining informed consent is the foundational step that must be prioritized.
Which additional finding confirms the diagnosis that the patient has mastitis?
- A. Enlarged glands in the axilla
- B. Normal temperature
- C. Engorged both breasts
- D. Hard mass and reddened area
Correct Answer: D
Rationale: A hard mass and a reddened area on one breast are key clinical signs that confirm the diagnosis of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, and swelling of the breast. The presence of a hard mass along with the other symptoms suggests inflammation and infection within the breast tissue. In contrast, the other findings such as enlarged glands in the axilla, normal temperature, and engorged breasts are not specific findings for mastitis and may be present in other conditions. Therefore, the presence of a hard mass and reddened area on one breast is the additional finding that strongly confirms the diagnosis of mastitis in this case.
A patient with a history of multiple myeloma presents with weakness, bone pain, and recurrent infections. Laboratory tests reveal anemia, hypercalcemia, renal insufficiency, and monoclonal spike on serum protein electrophoresis. Which of the following conditions is most likely to cause these findings?
- A. Waldenstrom macroglobulinemia
- B. Hodgkin lymphoma
- C. Chronic lymphocytic leukemia (CLL)
- D. Multiple myeloma
Correct Answer: D
Rationale: Multiple myeloma is a plasma cell neoplasm characterized by the presence of abnormal monoclonal plasma cells in the bone marrow, which produce a monoclonal spike on serum protein electrophoresis. The clinical presentation of weakness, bone pain, and recurrent infections is typical of multiple myeloma. Anemia can result from bone marrow infiltration by the abnormal plasma cells, hypercalcemia is due to bone destruction and release of calcium, renal insufficiency can result from hypercalcemia and protein deposition in the kidneys, and the monoclonal spike in serum protein electrophoresis indicates the presence of a monoclonal protein. Waldenström macroglobulinemia, Hodgkin lymphoma, and chronic lymphocytic leukemia do not typically present with the classic tetrad of findings seen in multiple myeloma.
A patient with a history of heart failure is prescribed digoxin. Which assessment finding indicates a potential adverse effect of digoxin therapy?
- A. Bradycardia
- B. Hypotension
- C. Hyperkalemia
- D. Confusion
Correct Answer: D
Rationale: Confusion is a potential adverse effect of digoxin therapy. Digoxin toxicity can manifest as various central nervous system symptoms, including confusion, delirium, and disorientation. It is important to monitor for signs of digoxin toxicity in patients taking this medication, especially those with a history of heart failure or renal impairment. Other common signs of digoxin toxicity may include visual disturbances (like halos around lights), gastrointestinal symptoms (like nausea and vomiting), and cardiac arrhythmias. Monitoring serum digoxin levels can help guide therapy and identify toxicity early.