A patient is exhibiting classic sign of a hemorrhagic stroke. What report from the patient would be an indicator of this type of stroke?

Correct Answer: B

Rationale: A severe headache is a classic sign of a hemorrhagic stroke. Hemorrhagic stroke occurs when a blood vessel in the brain ruptures and causes bleeding. This bleeding can lead to increased pressure within the skull, resulting in a sudden and severe headache. Other symptoms of a hemorrhagic stroke may include nausea, vomiting, sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, and loss of coordination. It is important to seek immediate medical attention if someone is experiencing symptoms of a stroke, including a severe headache, as prompt treatment is crucial in minimizing damage and improving outcomes.

Correct Answer: A

Rationale: The BEST position for a patient in shock is the modified Trendelenburg position. In this position, the patient's legs are elevated above the level of the heart to enhance blood flow back to the heart and vital organs. Placing the patient in the modified Trendelenburg position helps increase venous return, improves cardiac output, and promotes perfusion to vital organs, which can be crucial in managing shock. This position can help stabilize the patient's condition while awaiting further medical intervention.

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: D

Rationale: Pemoline (Cylert) is a central nervous system stimulant used in the treatment of ADHD. One of the significant potential side effects of pemoline is hepatotoxicity, which can manifest as elevated liver function test results. Therefore, the nurse must monitor the patient's liver function regularly while they are taking pemoline to monitor for any signs of liver damage or dysfunction. It is essential to educate the patient about the signs and symptoms of liver problems, such as jaundice (yellowing of the skin or eyes), abdominal pain, nausea, or dark urine, and to report any such symptoms immediately to their healthcare provider. Regular monitoring and early detection of liver function abnormalities can help prevent severe liver damage in patients taking pemoline.

Correct Answer: A

Rationale: When a woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures, the nurse should prioritize providing continuous labor support. Continuous labor support, also known as a doula or labor companion, has been shown to be effective in reducing the perception of pain and improving labor outcomes. The presence of a supportive person can provide physical, emotional, and informational support, helping the woman cope with the pain and navigate through the labor process. This intervention can enhance the woman's overall experience of labor and improve maternal and neonatal outcomes without the need for pharmacological interventions. Administering opioids, performing epidural analgesia, or initiating nitrous oxide inhalation are pharmacological pain relief measures and may not align with the woman's preference for non-pharmacological options.

Correct Answer: A

Rationale: Zenker's diverticulum is a condition in which there is a pouch or sac that forms at the posterior pharyngeal wall above the upper esophageal sphincter. It can present with symptoms such as sensation of a foreign body stuck in the throat, difficulty swallowing (dysphagia), and odynophagia (painful swallowing). Flexible laryngoscopy can reveal a submucosal mass arising from the posterior pharyngeal wall, which is characteristic of Zenker's diverticulum.

Correct Answer: A

Rationale: The scenario described, including cyclic pelvic pain, dysmenorrhea, dyspareunia, retroverted uterus, and a nodular mass behind the uterus, is most indicative of endometriosis. Endometriosis is a gynecological condition in which tissue similar to the endometrium (the tissue that lines the uterus) is found outside the uterus, typically on structures within the pelvis. The presence of endometrial tissue in abnormal locations can lead to symptoms such as pelvic pain, especially during menstruation (dysmenorrhea), painful intercourse (dyspareunia), and the formation of nodular masses (endometriomas) that can be felt on pelvic examination. It is important to note that while adenomyosis and uterine fibroids (leiomyomas) can also cause pelvic pain and dysmenorrhea, the specific findings of retroverted uterus and palpable nodular mass behind

Correct Answer: C

Rationale: The main source of nutrition for the baby during pregnancy is the placenta. The placenta is an organ that develops inside the uterus during pregnancy and provides essential nutrients and oxygen from the mother's blood to the baby through the umbilical cord. It acts as a barrier, protecting the baby from harmful substances while allowing necessary nutrients to pass through. The amniotic fluid serves as a protective cushion for the baby, the uterus provides the space for the baby to grow, and chorionic villi are small, hair-like structures on the placenta that aid in the exchange of nutrients and waste between the mother and the baby. However, the primary source of nutrition for the baby is the placenta, making option C the correct answer in this scenario.

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.