A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.

Correct Answer: A

Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.

Correct Answer: D

Rationale: The correct answer is D, marginal. Placenta previa is classified based on the proximity of the placental edge to the internal os. In a marginal placenta previa, the placental edge just reaches the internal os. This is a crucial distinction as it poses a higher risk for bleeding during labor. Total placenta previa covers the entire internal os, partial placenta previa partially covers the internal os, and low-lying placenta is when the placenta is close to but not covering the internal os. Therefore, D is correct as it accurately describes the specific position of the placenta edge in relation to the internal os in cases of marginal placenta previa.

Correct Answer: D

Rationale: The correct answer is D: Obese. This classification is based on the Body Mass Index (BMI) calculation, which takes into account weight and height. A BMI above 30 is considered obese, indicating excess body fat. Other choices are incorrect because they do not align with the BMI criteria for obesity. Choice A is incorrect as normal weight falls within a specific BMI range. Choice B is incorrect for individuals with a BMI below the normal range. Choice C is incorrect for individuals with a BMI between the overweight and obese categories.

Correct Answer: B

Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage. Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.

Correct Answer: A

Rationale: The correct answer is A: A referral for a mammogram. Given the family history of breast cancer in the patient's father, the nurse should recommend a mammogram as a preventive measure due to increased risk. Mammograms are effective in detecting breast cancer early, especially in individuals with a family history. This can help in early diagnosis and timely intervention if needed. B: Instructions about breast self-examination (BSE) can be helpful, but in this case, a mammogram is a more definitive screening tool for high-risk individuals. C: A referral to a surgeon is not necessary at this point as the patient does not exhibit any symptoms of breast cancer. D: Referral to a support group may be beneficial for emotional support, but the priority should be on proactive screening measures like a mammogram.

Correct Answer: C

Rationale: Step 1: Increased urine output indicates improved kidney function, a key indicator of recovery from preeclampsia. Step 2: Adequate urine output helps regulate blood pressure and reduce swelling. Step 3: Consistent urine output >100 mL/hour signifies the kidneys are functioning properly. Step 4: Therefore, C is the correct answer as it directly reflects recovery progress from preeclampsia. Summary: A, B, and D are incorrect as they do not directly correlate with kidney function or recovery from preeclampsia.

Correct Answer: C

Rationale: The correct answer is C: Emotional exhaustion. Dealing with others' pain daily can lead to burnout and emotional exhaustion for the nurse. This can result in decreased empathy and effectiveness in providing care. Healthy practices such as self-care, setting boundaries, and seeking support can help prevent emotional exhaustion. Choice A: Inefficiency in the provision of care is incorrect because emotional exhaustion may affect the quality of care but does not necessarily lead to inefficiency. Choice B: Excessive weight gain is incorrect as it is not directly related to the emotional toll of dealing with others' pain. Choice D: Social withdrawal is incorrect as it is a potential outcome of emotional exhaustion but not the primary concern in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Recurrent pelvic infections. Pelvic infections can lead to scarring and blockage of the fallopian tubes, increasing the risk of ectopic pregnancy. Ovarian cysts and oral contraceptives are not directly linked to ectopic pregnancies. Heavy menstrual flow does not inherently increase the risk of ectopic pregnancy.

Correct Answer: A

Rationale: The correct answer is A: Hypoglycemia. Infants of diabetic mothers are at risk for hypoglycemia due to excessive insulin production in response to high glucose levels in utero. Monitoring blood glucose levels is crucial to prevent hypoglycemia-related complications. B: Hypercalcemia is not a major neonatal complication seen in infants of diabetic mothers. C: Hypoinsulinemia refers to low levels of insulin, which is not typically a concern in infants of diabetic mothers. D: Hypobilirubinemia is not a common complication in infants of diabetic mothers. In summary, monitoring for hypoglycemia is essential in infants of diabetic mothers to prevent potential complications.