A patient appears confused and disoriented during a consultation. What is the nurse's priority?

Correct Answer: B

Rationale: The nurse's priority when a patient appears confused and disoriented during a consultation is to provide clear and simple explanations and assess for any underlying causes of confusion. It is essential to ensure that the patient understands the information being provided and to address any potential reasons for the confusion, such as medication side effects, medical conditions, or cognitive impairment. Ignoring the patient's confusion or assuming they cannot understand can lead to misunderstandings, errors in care, and ultimately jeopardize the patient's well-being. It is crucial to approach the situation with empathy, patience, and a focus on ensuring effective communication and understanding between the nurse and the patient.

Correct Answer: B

Rationale: Nitrous oxide, also known as "laughing gas," is a safe and effective pharmacological option for pain management during labor. Nitrous oxide is commonly used in labor and delivery settings as it has minimal effects on the baby and allows the woman to remain in control of her pain management. It provides quick pain relief when inhaled and can be adjusted to the woman's needs during labor. Ibuprofen, morphine, and diazepam are not typically used for pain management during labor due to their potential risks and side effects, especially for the baby.

Correct Answer: A

Rationale: The patient's lack of sensation in her right leg, allowing her cat to scratch her without her noticing, is indicative of neuropathy. Neuropathy is a common diabetic complication characterized by nerve damage that can result in loss of sensation or altered sensation in different parts of the body, including the extremities. In this case, neuropathy has likely affected the patient's right lower extremity, leading to her inability to feel the cat scratching her leg and resulting in the unnoticed scratches, infection, and subsequent cellulitis.

Correct Answer: A

Rationale: Plasma cells are the primary type of cells responsible for the production of antibodies during the humoral immune response. When activated by antigens, B cells differentiate into plasma cells, which are specialized in producing large quantities of antibodies. These antibodies are essential in fighting off infections by binding to antigens and marking them for destruction by other immune cells. T helper cells assist in activating B cells, but the actual production of antibodies is mainly carried out by plasma cells. Memory B cells are involved in mounting a rapid and specific secondary response upon re-exposure to the same antigen. Macrophages play a role in phagocytosis and antigen presentation, but they are not the primary cells responsible for producing antibodies during the humoral immune response.

Correct Answer: A

Rationale: A nursing assistant can be delegated the task of changing wound dressings because it is considered a basic nursing care activity that does not require specialized training or knowledge. Nursing assistants are trained to perform tasks related to personal care, hygiene, and basic wound care under the supervision of a registered nurse. Changing wound dressings is a routine nursing task that can be safely delegated to a nursing assistant, allowing the nurse to focus on other aspects of patient care that require specialized nursing skills and knowledge.

Correct Answer: C

Rationale: Scabies is a contagious skin infestation caused by the Sarcoptes scabiei mite. The classic presentation of scabies includes a rash characterized by erythematous papules and vesicles that are arranged in a linear or burrow-like distribution. These linear tracks are often seen in areas such as the interdigital spaces, wrists, elbows, axillae, belt line, and genitalia. It is commonly associated with intense itching, especially at night. Unlike psoriasis, which presents with silvery scales and well-defined borders, or contact dermatitis, which results from exposure to a specific allergen or irritant, scabies is caused by a parasitic mite infestation. Atopic dermatitis, on the other hand, is a chronic inflammatory skin condition characterized by pruritic eczematous lesions, but it typically does not manifest with a linear distribution of lesions like scabies.

Correct Answer: A

Rationale: The nurse should prioritize adjusting the irrigation flow rate based on the patient's urine output to prevent complications during continuous bladder irrigation (CBI). Proper adjustment of the irrigation flow rate helps maintain adequate bladder drainage while preventing bladder distention, clot formation, and potential irrigation fluid overload. Monitoring the patient's urine output and adjusting the flow rate accordingly ensures optimal functioning of the CBI system and enhances patient safety. This proactive approach minimizes the risk of complications and promotes effective postoperative care following urological surgery.

Correct Answer: B

Rationale: Thrombotic thrombocytopenic purpura (TTP) is a rare blood disorder characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, neurological abnormalities, and renal dysfunction. The peripheral blood smear in TTP typically shows fragmented red blood cells (schistocytes) due to mechanical destruction within small blood vessels. Laboratory findings in TTP commonly include elevated lactate dehydrogenase (LDH), decreased haptoglobin (as it is consumed in the clearance of free hemoglobin), and increased indirect bilirubin due to increased red blood cell breakdown. This combination of clinical presentation and laboratory abnormalities is classic for TTP. Hemolytic uremic syndrome (HUS) may present similarly but is more commonly associated with renal dysfunction and is often triggered by infection with Shiga toxin-producing E. coli.

Correct Answer: A

Rationale: The first step in the management of a chemical splash to the eyes is to irrigate the eyes with clean water. Flushing the affected eye with water helps to remove the chemical and minimize any potential injury. It is important to continue irrigation for at least 15-20 minutes to ensure thorough removal of the chemical. This prompt action can help prevent further damage to the eye and surrounding tissue. It is crucial to remember not to delay irrigation to seek medical advice first, as immediate irrigation is vital in such situations. After irrigating the eyes, further assessment and treatment can be carried out based on the severity of the injury.