A nurse is preparing to assist with a lumbar puncture procedure for a patient. What action should the nurse take to maintain procedural asepsis?

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Question 1 of 9

A nurse is preparing to assist with a lumbar puncture procedure for a patient. What action should the nurse take to maintain procedural asepsis?

Correct Answer: A

Rationale: A nurse should wear sterile gloves and a surgical mask during a lumbar puncture procedure to maintain procedural asepsis. Sterile gloves help prevent contamination of the procedure site and reduce the risk of introducing microorganisms to the puncture site. Surgical masks help minimize the risk of respiratory secretions contaminating the sterile field, which is essential for maintaining asepsis during the procedure. Additionally, proper hand hygiene before and after the procedure is crucial in preventing the spread of infection.

Question 2 of 9

A patient presents with sudden-onset severe lower abdominal pain, nausea, vomiting, and inability to pass urine. On physical examination, there is suprapubic tenderness and a palpable bladder. What is the most likely diagnosis?

Correct Answer: B

Rationale: The patient's presentation with sudden-onset severe lower abdominal pain, nausea, vomiting, inability to pass urine, suprapubic tenderness, and a palpable bladder is classic for acute urinary retention. Acute urinary retention is a urological emergency characterized by the sudden inability to pass urine due to the inability to empty the bladder completely. The palpable bladder on physical examination indicates significant bladder distension. This condition can be caused by multiple factors such as bladder outlet obstruction, neurogenic causes, or medications affecting bladder function. Prompt intervention is necessary to relieve the bladder distension, alleviate symptoms, and prevent complications like bladder rupture.

Question 3 of 9

Which intervention should the nurse use to promote rest?

Correct Answer: A

Rationale: Developing a routine with the patient to balance her studies and rest needs is the most appropriate intervention to promote rest. This approach considers the patient's responsibilities and can help her organize her time effectively to ensure she gets adequate rest while managing her studies. It acknowledges the importance of rest without completely disregarding the patient's other commitments, ultimately fostering a balanced approach to self-care. This intervention is patient-centered and collaborative, empowering the patient to take an active role in prioritizing rest alongside her educational responsibilities.

Question 4 of 9

A patient presents with sudden-onset severe headache, altered mental status, and focal neurological deficits. Imaging reveals a hemorrhagic lesion within the subarachnoid space. Which of the following neurological conditions is most likely responsible for these symptoms?

Correct Answer: D

Rationale: A subarachnoid hemorrhage is characterized by bleeding within the subarachnoid space, the area between the arachnoid mater and the pia mater surrounding the brain. Patients typically present with a sudden-onset severe headache, altered mental status, and focal neurological deficits due to the mass effect of the blood in the subarachnoid space. Imaging, such as a CT scan, can confirm the presence of the hemorrhagic lesion. Ischemic stroke results from a blockage in the blood vessels supplying the brain, leading to tissue infarction and neurological deficits. Subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, commonly seen following head trauma. Intracerebral hemorrhage involves bleeding within the brain tissue itself, often leading to focal neurological deficits.

Question 5 of 9

Which of the following statements should Nurse Cora consider as TRUE with anorexia nervosa?

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.

Question 6 of 9

A patient with a history of heart failure is prescribed digoxin. Which assessment finding indicates a potential adverse effect of digoxin therapy?

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.

Question 7 of 9

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?

Correct Answer: C

Rationale: The described presentation of a yellowish-white spot on the cornea with a ring of inflammation, along with branching, filamentous opacities extending from the corneal lesion, is characteristic of fungal keratitis. Fungal keratitis typically presents with these specific features on clinical examination.

Question 8 of 9

The patient during labor would anticipate some emotional support. Which of the following nursing interventions should Nurse Sarah provide to keep the patient calm?

Correct Answer: B

Rationale: Support in maintaining a sense of control is essential in keeping the patient calm during labor. Giving the patient a sense of control allows them to feel empowered and more in charge of their experience. This can help reduce anxiety and fear, ultimately promoting a more positive and calm labor experience. Providing emotional support by assisting the patient in maintaining control can greatly benefit their overall emotional well-being during this stressful time.

Question 9 of 9

The nurse develops the following hypothesis: Elderly women receive less aggressive treatment for terminally-ill spine patients than younger women. Which variable would be considered to be the independent variable?

Correct Answer: B

Rationale: The independent variable in an experiment is the variable that is manipulated or determined by the researcher. In this hypothesis, the nurse is suggesting that the age of the patient (elderly vs. younger) influences the aggressiveness of treatment received. Therefore, the age of the patient is the independent variable in this scenario. The dependent variable would be the degree of treatment received, as it is expected to be influenced by the independent variable, which is the age of the patient.

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