A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?

Correct Answer: B

Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.

Correct Answer: C

Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not develop normally. In infants, one of the signs of DDH is the presence of asymmetry of gluteal (buttock) and thigh folds. This is due to the dislocated or subluxed hip being positioned differently than the healthy hip. The nurse should look for this sign during the assessment of a 2-week-old infant to help identify potential hip joint problems early on. Excessive hip abduction, femoral lengthening of an affected leg, and pain when lying prone are not typical signs of DDH in a 2-week-old infant.

Correct Answer: C

Rationale: When evaluating the effectiveness of nursing interventions for sinusitis discomfort, assessing the amount and color of sinus drainage is crucial. Changes in these aspects can provide valuable information about the progression of the sinusitis and the effectiveness of the interventions being implemented. Increased or purulent sinus drainage can indicate infection or inflammation, while clearer drainage may suggest improvement. Monitoring these parameters helps the nurse make informed decisions about continuing, modifying, or discontinuing interventions to manage the patient's sinusitis discomfort effectively. Evaluating WBC count, capillary refill, and comfort level are also important assessments in certain situations, but assessing the amount and color of sinus drainage is most directly related to sinusitis symptoms.

Correct Answer: A

Rationale: Corticosteroids are the mainstay of therapy for minimal change nephrotic syndrome. Minimal change disease is the most common cause of nephrotic syndrome in children, and corticosteroids are highly effective in inducing remission in these patients. They work by reducing inflammation and decreasing the permeability of the glomerular filtration barrier in the kidneys, thereby reducing proteinuria. Antihypertensive agents are used to control blood pressure in patients with renal involvement, and long-term diuretics are not typically recommended in nephrotic syndrome due to the risk of worsening kidney function. Increased fluids to promote diuresis are also not indicated as the primary treatment for minimal change nephrotic syndrome.

Correct Answer: B

Rationale: Fatigue in a patient with heart failure is commonly caused by decreased cardiac output. In heart failure, the heart is unable to pump enough blood to meet the body's demands, resulting in reduced delivery of oxygen and nutrients to the tissues. This can lead to generalized weakness and fatigue. Dyspnea (choice A) is commonly associated with heart failure but is more specific to difficulty breathing, while a dry cough (choice C) is a symptom that can be present but is not typically the primary cause of fatigue. Orthopnea (choice D) is a symptom of heart failure characterized by difficulty breathing when lying flat but is not directly related to the patient's increasing fatigue in this scenario.