Nokea
Who should Nurse Sandra consider as a priority for home visitation?
- A. Pedro 9 years old whose parents are both workings
- B. Mellisa 10 years old with stunted growth for her age
- C. Cindy 7 years old who has been absent due to skin lesions
- D. Mike 8 years old who often sleeps during class hour.
Correct Answer: C
Rationale: Nurse Sandra should consider Cindy, 7 years old who has been absent due to skin lesions, as a priority for home visitation. Skin lesions can indicate potential health issues that need to be addressed promptly. Cindy's frequent absences could be a sign that her condition is affecting her school attendance and overall well-being. By conducting a home visit, Nurse Sandra can assess Cindy's living environment, provide appropriate care recommendations, and ensure that she receives necessary medical attention. This proactive approach can help address Cindy's health concerns and support her academic performance.
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When preparing the patient for suctioning, what is the FIRST step?
- A. Perform hand hygiene
- B. Gather equipment
- C. Assess lung sounds, heart rate and rhythm
- D. Check physician's order and patient care plan
Correct Answer: D
Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.
A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?
- A. Anterior uveitis
- B. Acute angle-closure glaucoma
- C. Endophthalmitis
- D. Corneal abrasion
Correct Answer: A
Rationale: The presentation described in the question is most consistent with anterior uveitis. Anterior uveitis, also known as iritis, is characterized by redness, pain, and photophobia in the affected eye. Slit-lamp examination typically reveals ciliary injection (reddening of the conjunctiva and episclera), corneal edema, and a mid-dilated pupil with a fixed reaction to light (miosis). This occurs due to inflammation within the anterior chamber of the eye involving the iris and ciliary body.
The patient record (charts) are collected every three nights from the various departments. The night nurse is EXPECTED to do the following, EXCEPT,
- A. ensure the correct order of the chart.
- B. see to the completeness of the chart pages.
- C. bind the charts as they are
- D. tape or repair torn pages
Correct Answer: C
Rationale: The night nurse is expected to collect the patient charts from various departments every three nights. Among the tasks listed, binding the charts as they are is not typically a responsibility of the night nurse. This task is usually handled by administrative staff or professional medical records technicians who are trained to manage the organization and storage of patient charts. The night nurse's primary focus should be on ensuring the correct order of the charts, checking for completeness, and addressing any issues such as torn pages by taping or repairing them to maintain the integrity of the patient records.
A pregnant woman presents with fever, chills, and abdominal pain localized to the right lower quadrant. On examination, she has rebound tenderness and guarding. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Acute appendicitis
- D. Ovarian torsion
Correct Answer: C
Rationale: Acute appendicitis is the most likely cause of the symptoms described in the pregnant woman. The classic presentation of acute appendicitis includes fever, chills, abdominal pain localized to the right lower quadrant, rebound tenderness, and guarding. Pregnant women are at a slightly higher risk of developing appendicitis due to anatomic changes and increased abdominal pressure during pregnancy, which can lead to an atypical presentation of symptoms. Prompt diagnosis and surgical intervention are crucial to prevent complications such as perforation, which can be detrimental for both the mother and the fetus.
A patient presents with a small, painless, well-defined nodule on the lateral aspect of the neck, just above the clavicle. Fine-needle aspiration cytology reveals clusters of polygonal cells with abundant granular cytoplasm. Which of the following conditions is most likely responsible for this presentation?
- A. Thyroglossal duct cyst
- B. Branchial cleft cyst
- C. Lymphadenopathy
- D. Parathyroid adenoma
Correct Answer: D
Rationale: The presentation described is characteristic of a parathyroid adenoma. Parathyroid adenomas are benign neoplasms that can present as painless, well-defined nodules usually located in the lower pole of the thyroid gland or in close proximity, such as the lateral aspect of the neck above the clavicle. Fine-needle aspiration cytology of a parathyroid adenoma typically reveals polygonal cells with abundant granular cytoplasm, often referred to as chief cells. This is key in differentiating it from other conditions mentioned in the question.