A patient presents with multiple grouped vesicles on an erythematous base, affecting the genital area. The patient reports a history of similar lesions in the past, occurring during periods of stress. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: A

Rationale: The presentation described, involving multiple grouped vesicles on an erythematous base in the genital area, is classic for herpes simplex genitalis. This condition is caused by the herpes simplex virus (HSV) and is characterized by recurrent outbreaks of painful vesicles in the genital or perianal area. The history of similar lesions occurring during periods of stress is also suggestive of herpes simplex virus reactivation. Genital warts (condyloma acuminata) typically present as painless, fleshy growths in the genital area caused by human papillomavirus (HPV). Syphilis manifests as a painless ulcer known as a chancre, which is not described in the presentation. Molluscum contagiosum presents with pearly, dome-shaped papules with central umbilication, rather than vesicles.

Correct Answer: B

Rationale: When managing a conscious patient with a severe nosebleed (epistaxis), the appropriate intervention is to have the patient sit upright and lean slightly forward to prevent blood from flowing into the throat and causing choking or swallowing. Pinching the soft part of the nose just below the bony part can help apply pressure to the bleeding vessel and stop the bleeding. This maneuver also helps compress the blood vessels in the nose, promoting clot formation and stopping the bleeding. It is important not to tilt the head back as this can cause blood to flow into the throat and potentially lead to swallowing, choking, or aspiration. Packing the nose with cotton gauze should be done by medical professionals if the bleeding does not stop with direct pressure. Applying direct pressure to the forehead is not effective for managing nosebleeds; pressure should be applied to the nostrils instead.

Correct Answer: C

Rationale: A dental abscess is characterized by a localized collection of pus that results from a bacterial infection of the tooth pulp, leading to swelling, pain, and inflammation. The infection typically occurs when bacteria enter the tooth through a cavity, crack, or other dental injury. The abscess can cause significant pain and discomfort and must be treated promptly by a dentist to prevent further complications. Dental caries refer to tooth decay or cavities that result from the breakdown of tooth structure by acids produced by bacteria. Periodontitis is a severe gum infection that damages the soft tissue and destroys the bone that supports the teeth. Oral candidiasis is a fungal infection that affects the mouth and throat.

Correct Answer: B

Rationale: The nurse's priority action after noticing a sudden drop in blood pressure after administering anesthesia is to assess the patient's airway, breathing, and circulation (ABCs). This is crucial to determine the immediate cause of the sudden drop in blood pressure and to ensure the patient's safety and stability. Assessment of the ABCs will help identify any potential airway obstruction, respiratory distress, or circulatory issues that may be contributing to the drop in blood pressure. Once the assessment is done, appropriate interventions can be initiated to stabilize the patient's condition. Administering vasopressors, documenting the blood pressure readings, and notifying the anesthesiologist are important actions but assessing the ABCs takes precedence in this situation to ensure the patient's immediate needs are addressed.

Correct Answer: A

Rationale: When a patient is in a somnolent status and still under the effect of anesthesia, the most appropriate position to place the patient is in a supine position with the head of the bed slightly elevated. This position helps prevent any obstruction of the airway and promotes optimal ventilation. Elevating the head of the bed ensures that the patient's airway remains clear and allows for proper breathing. Additionally, this position helps prevent aspiration and promotes proper circulation. Overall, the supine position with the head bed slightly elevated is the safest and most effective position for a patient in this condition.

Correct Answer: B

Rationale: The priority nursing diagnosis for a patient undergoing surgery (closure of the sac) would be risk for infection. This is because surgical procedures increase the risk of infection due to the breach in the skin and introduction of microorganisms. Infection can lead to serious complications, delay healing, and prolong recovery time. Therefore, prevention, early detection, and prompt treatment of infections are essential in the perioperative period to ensure the best possible outcomes for the patient.

Correct Answer: B

Rationale: Ella's statement "I will hang myself" directly indicates a desire and intent to commit suicide. This is classified as a suicidal intent, which is a serious concern that requires immediate attention and intervention. It is crucial to take any mention or indication of suicide seriously and seek help from mental health professionals or crisis intervention services.

Correct Answer: D

Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.

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.