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: C

Rationale: The PRIORITY nursing action of the nurse for Jose due for oxygen therapy is to turn on the oxygen. Ensuring that the oxygen is turned on is the necessary first step before any other actions can be effective in delivering oxygen to the patient. Without oxygen being turned on, all other steps such as attaching the humidifier, connecting tubing, or adjusting the flow rate would be ineffective in providing the necessary oxygen therapy to the patient. Therefore, turning on the oxygen is the most crucial initial step to take in this situation to ensure that the patient receives the needed oxygen promptly and safely.

Correct Answer: B

Rationale: When a patient receiving palliative care for end-stage cancer experiences severe nausea and vomiting despite current antiemetic therapy, the palliative nurse should consider switching to a different antiemetic medication with a different mechanism of action. This approach is based on the concept of individual variability in response to medications, as well as the potential development of tolerance to a particular drug. Switching to a different antiemetic with a new mechanism of action can provide the patient with a fresh chance at better symptom control by targeting different receptors or pathways involved in nausea and vomiting. It is important to consult the healthcare team and consider the patient's overall condition and medication history before making any changes in the treatment plan.

Correct Answer: B

Rationale: Vitamin K is essential for the production of several clotting factors in the liver, including factors II, VII, IX, and X. In a patient with chronic liver disease, impaired liver function can lead to decreased synthesis of these clotting factors. As a result, there is an underlying deficiency of these clotting factors, leading to prolonged PT (prothrombin time) and aPTT (activated partial thromboplastin time). The mixing studies showing correction with normal plasma further support the diagnosis of a factor deficiency rather than an inhibitor, which helps in ruling out conditions like DIC or hemophilia.

Correct Answer: A

Rationale: The purpose of a tracheostomy is to establish an artificial airway in the trachea through a surgical procedure. This is done to bypass obstructions in the upper airway, assist with breathing, or facilitate the removal of secretions from the lungs. A tracheostomy helps in maintaining a clear and secure airway for patients who have difficulty breathing or require long-term mechanical ventilation support.

Correct Answer: B

Rationale: Beta-blockers work by blocking the effects of adrenaline on beta receptors in the body. One common adverse effect of beta-blockers is bradycardia, or a slowed heart rate. Since the patient is being prescribed a beta-blocker for migraine headaches, it is important for the nurse to monitor closely for signs and symptoms of bradycardia such as dizziness, fatigue, and fainting. Monitoring the heart rate regularly and reporting any significant decrease to the healthcare provider is essential to prevent complications associated with bradycardia. Compared to the other options, bradycardia is the most relevant adverse effect to monitor in a patient prescribed a beta-blocker.

Correct Answer: B

Rationale: The presentation of a patient with diabetes mellitus showing symptoms of polyuria, polydipsia, nocturia, and fatigue along with laboratory findings of hyperglycemia, glycosuria, and ketonuria is indicative of diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. The increased glucose levels lead to glycosuria, causing osmotic diuresis resulting in polyuria, polydipsia, and nocturia. The body starts breaking down fats for energy in the absence of sufficient insulin, leading to the production of ketones causing ketonuria. The patient may also experience fatigue due to the metabolic abnormalities present in DKA.

Correct Answer: B

Rationale: The appropriate way to correct an error in the Nurses Notes is to draw a single line across the error and initial it. This method is recommended because it indicates that there was an error made, while still preserving the original information for audit and legal purposes. It shows transparency and accountability in documentation, as the original information remains visible. Taking the whole page out and replacing it with a fresh one can lead to discrepancies and potential legal issues if there are inconsistencies in the documentation. Using methods like using the sticky side of the plastic tape or a rubber eraser can make the documentation look unprofessional and raises questions about the accuracy and integrity of the notes.

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.