A nurse is preparing to perform an intramuscular (IM) injection for a patient. What action should the nurse take to ensure proper injection technique?

Correct Answer: D

Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.

Correct Answer: A

Rationale: The presentation described with sudden-onset, painless vision loss, a cherry-red spot at the macula, and attenuated retinal vessels is classic for central retinal artery occlusion (CRAO). CRAO occurs when the central retinal artery, which supplies blood to the inner retinal layers, becomes occluded. The cherry-red spot is due to the exposure of the underlying choroid, which still appears red as it is not affected by the blockage. Attenuated retinal vessels and a pale retina may also be seen due to ischemia. In contrast, central retinal vein occlusion (choice B) presents with sudden painless vision loss, retinal hemorrhages, dilated retinal veins, and cotton-wool spots. Retinal detachment (choice C) typically presents with flashes, floaters, and a curtain-like shadow across the vision. Acute angle-closure glaucoma (

Correct Answer: D

Rationale: Radical abdominal hysterectomy involves the removal of the uterus, ovaries, ligaments (including round ligaments and uterosacral ligaments), and fallopian tubes. This extensive procedure is typically done for cases of invasive gynecologic cancers, most commonly cervical or ovarian cancer. The goal of radical hysterectomy is to remove as much of the cancerous tissue as possible to improve the chances of successful treatment and reduce the risk of cancer recurrence.

Correct Answer: A

Rationale: Von Willebrand disease is a hereditary bleeding disorder that results from a deficiency or dysfunction of von Willebrand factor (vWF), a protein that plays a key role in platelet adhesion and the initiation of primary hemostasis. The clinical manifestations of von Willebrand disease include recurrent mucocutaneous bleeding, such as nosebleeds, easy bruising, and gum bleeding. Laboratory findings typically show a prolonged bleeding time due to impaired platelet function, while platelet count, PT (prothrombin time), and aPTT (activated partial thromboplastin time) are usually normal. This distinguishes von Willebrand disease from other bleeding disorders such as hemophilia A (Factor VIII deficiency), which would show abnormal PT and aPTT due to deficiencies in specific clotting factors. Thrombocytopenia, on the other hand, would be characterized by a low platelet count

Correct Answer: A

Rationale: The appropriate sequence of steps in the assessment of a conscious trauma patient is the ABCDE approach, which stands for Airway, Breathing, Circulation, Disability, and Exposure.

Correct Answer: B

Rationale: The nurse's best response to a patient expressing fear of the unknown regarding an upcoming surgical procedure is to provide the patient with accurate information about the surgical procedure and what to expect. This approach empowers the patient with knowledge and helps alleviate anxiety by demystifying the unknown. By educating the patient about the procedure, potential risks, and postoperative care, the nurse can help the patient feel more prepared and in control of the situation. It is crucial for healthcare providers to address patient fears with compassion, understanding, and information to support the patient through the surgical process.

Correct Answer: C

Rationale: In this scenario, the nurse can be sued for malpractice. Malpractice refers to the failure of a professional, in this case, a nurse, to provide the standard of care that a reasonably prudent nurse would have provided in similar circumstances, resulting in harm to the patient. Administering an extra dose of vaccine leading to an adverse reaction and death of the patient is considered a form of medical malpractice as it involves a breach in the standard of care. Generally, malpractice cases involve errors or negligence in the performance of professional duties, which result in harm to the patient.

Correct Answer: C

Rationale: In the context of CO-PAR (Community Organizing Participatory Action Research), the most important role of the public health nurse is being an expert. Public health nurses are expected to have specialized knowledge and skills in the field of public health, allowing them to provide evidence-based guidance and interventions to support community health initiatives. As an expert, the public health nurse can assess community needs, develop appropriate interventions, educate community members on health promotion and disease prevention, and evaluate the effectiveness of implemented programs. By utilizing their expertise, public health nurses can effectively contribute to improving the health outcomes and well-being of the community they serve.

Correct Answer: C

Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.