Nokea
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.
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Nurse Adalynn discusses the possibilities of future postpartum hemorrhage with the patients. Which of the following increases the absorption of vitamin K?
- A. Proteins
- B. Carbohydrates
- C. Minerals
- D. Fats
Correct Answer: D
Rationale: Fats are essential for the absorption of vitamin K in the body. Vitamin K is a fat-soluble vitamin, meaning it is better absorbed in the presence of dietary fats. In the case of postpartum hemorrhage, adequate levels of vitamin K are crucial for proper blood clotting. Thus, incorporating fats in the diet can help ensure sufficient absorption of vitamin K, which can be beneficial in preventing complications related to hemorrhage.
A postpartum client presents with sudden, severe chest pain and dyspnea. Which nursing action is most appropriate?
- A. Placing the client in a semi-Fowler's position
- B. Administering supplemental oxygen therapy
- C. Notifying the healthcare provider immediately
- D. Encouraging the client to perform deep breathing exercises
Correct Answer: C
Rationale: Sudden, severe chest pain and dyspnea in a postpartum client could be indicative of a potential serious condition, such as a pulmonary embolism or postpartum cardiomyopathy, which require immediate medical attention. Therefore, the most appropriate nursing action would be to notify the healthcare provider immediately for further evaluation and management. Placing the client in a semi-Fowler's position may provide some comfort but does not address the underlying cause of the symptoms. Administering supplemental oxygen therapy may be necessary once the healthcare provider assesses the client. Encouraging deep breathing exercises may not be appropriate if the client is experiencing severe chest pain and dyspnea, as it could worsen the situation.
A patient presents with a yellowish-white spot on the cornea, surrounded by a ring of inflammation. Slit-lamp examination reveals branching, filamentous opacities extending from the corneal lesion. Which of the following conditions is most likely responsible for this presentation?
- A. Herpes simplex keratitis
- B. Bacterial keratitis
- C. Fungal keratitis
- D. Acanthamoeba keratitis Dental, Alimentary, and Biliary
Correct Answer: C
Rationale: The presentation described is consistent with fungal keratitis. Fungal keratitis typically presents with a yellowish-white spot on the cornea, surrounded by a ring of inflammation. The filamentous opacities seen on slit-lamp examination are characteristic of fungal hyphae extending from the corneal lesion. This condition is often associated with risk factors such as trauma with vegetable matter, contact lens wear, or topical corticosteroid use. Prompt diagnosis and treatment with antifungal medications are essential to prevent complications and preserve vision.
What is the FIRST priority which the nurse must observe in caring for patient with seizure?
- A. Safety
- B. Nutrition
- C. Airway
- D. Mobility
Correct Answer: A
Rationale: The first priority for a nurse caring for a patient experiencing a seizure is safety. Ensuring the safety of the patient is crucial to prevent injury during the seizure episode. This includes clearing the area around the patient of any harmful objects, preventing the patient from falling or hitting their head, placing them in a safe position to prevent aspiration if they vomit, and staying with the patient until the seizure ends. Once the patient is safe, the nurse can then focus on other aspects of care such as assessing airway, providing emotional support, and monitoring for complications.
A patient receiving palliative care for end-stage amyotrophic lateral sclerosis (ALS) experiences difficulty swallowing and expresses concerns about choking. What intervention should the palliative nurse prioritize to address the patient's concerns?
- A. Encourage the patient to avoid eating solid foods to prevent choking.
- B. Refer the patient to a speech therapist for swallowing exercises and techniques.
- C. Administer sedative medications to reduce anxiety related to choking fears.
- D. Recommend inserting a feeding tube for nutritional support.
Correct Answer: B
Rationale: The most appropriate intervention for a patient with difficulty swallowing due to end-stage ALS and concerns about choking is to refer the patient to a speech therapist for swallowing exercises and techniques (Choice B). Speech therapists are trained to assess and manage swallowing difficulties in patients, especially those with neurodegenerative diseases like ALS. They can provide specific exercises and strategies to help the patient swallow safely and reduce the risk of choking. This intervention focuses on addressing the underlying issue causing the difficulty swallowing and aims to improve the patient's quality of life by enhancing their ability to eat and drink. The other options are not as effective or appropriate in addressing the patient's concerns.