A patient presents with recurrent episodes of postnasal drip, chronic cough, and halitosis. Nasal endoscopy reveals a foul-smelling, yellowish discharge draining from the middle meatus. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of postnasal drip, chronic cough, halitosis, and foul-smelling, yellowish discharge from the middle meatus is highly suggestive of chronic rhinosinusitis. The presence of nasal polyps further supports this diagnosis. Chronic rhinosinusitis with nasal polyps is characterized by inflammation of the paranasal sinuses, leading to symptoms such as nasal congestion, postnasal drip, cough, and a reduced sense of smell. The yellowish discharge and foul odor are typical findings in cases of chronic rhinosinusitis with secondary bacterial infection. Nasal endoscopy may reveal edematous nasal mucosa and polyps obstructing the middle meatus, contributing to the symptoms described by the patient. Management typically involves a combination of medical therapies such as intranasal corticosteroids, saline irrigation, and antibiotics, and in some cases, surgical intervention

Correct Answer: C

Rationale: The most effective intervention to prevent pressure ulcers in bedbound patients at risk, such as those with advanced dementia, is to use pressure-relieving support surfaces like specialized mattresses or cushions. These surfaces help distribute the pressure evenly, reducing the risk of pressure ulcer formation on bony prominences. Turning the patient every 2 hours (choice A) can also help relieve pressure, but it may not be sufficient to prevent pressure ulcers in high-risk individuals. Applying barrier creams or moisture barriers (choice B) can help protect the skin but may not address the underlying issue of pressure on vulnerable areas. Administering prophylactic antibiotics (choice D) is not recommended for preventing pressure ulcers as it does not address the root cause of the problem and can lead to antibiotic resistance. Therefore, the priority intervention should be to use pressure-relieving support surfaces to minimize the risk of pressure ulcers in

Correct Answer: B

Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.

Correct Answer: C

Rationale: Sudden, severe chest pain and dyspnea in a postpartum client could be indicative of a potential serious condition, such as a pulmonary embolism or postpartum cardiomyopathy, which require immediate medical attention. Therefore, the most appropriate nursing action would be to notify the healthcare provider immediately for further evaluation and management. Placing the client in a semi-Fowler's position may provide some comfort but does not address the underlying cause of the symptoms. Administering supplemental oxygen therapy may be necessary once the healthcare provider assesses the client. Encouraging deep breathing exercises may not be appropriate if the client is experiencing severe chest pain and dyspnea, as it could worsen the situation.

Correct Answer: D

Rationale: Negligence is the failure to take proper care in doing something, which results in harm or injury to someone else. In this scenario, the client falling out of bed because side rails were not used indicates a lack of proper care or attention by the staff or caregiver responsible for the client. It shows a failure to protect the client from harm, which aligns with the definition of negligence. This situation does not fit the definitions of a felony, battery, or assault.

Correct Answer: D

Rationale: The clinical presentation of chest pain, dyspnea, and a friction rub heard on auscultation is suggestive of pericarditis. The diffuse ST-segment elevation seen on the electrocardiogram (ECG) is a classic finding in pericarditis, known as the "universal sign." In contrast, stable angina typically presents with chest pain on exertion that is relieved by rest or nitroglycerin, while unstable angina presents with chest pain at rest or with minimal exertion. Acute myocardial infarction would typically present with ST-segment elevation in specific leads correlating with the area of myocardial ischemia/infarction. However, in the context of diffuse ST-segment elevation and symptoms suggestive of inflammation (friction rub), the most likely diagnosis is pericarditis.

Correct Answer: C

Rationale: Clients undergoing nasogastric suctioning are at highest risk for developing metabolic imbalances, specifically metabolic acidosis. Nasogastric suctioning can lead to the loss of gastric acid, which in turn can cause metabolic acidosis due to a decrease in bicarbonate levels in the body. This disruption in the acid-base balance can result in symptoms such as confusion, headache, and overall malaise. It is crucial for the nurse to monitor the client's acid-base status closely and provide appropriate interventions to prevent or correct metabolic acidosis.

Correct Answer: C

Rationale: In a missed abortion, the embryo has died, but the products of conception remain in the uterus, leading to the visualization of a gestational sac without an embryo on ultrasound. This is a type of missed miscarriage where the woman may not have any symptoms initially and the diagnosis is made during a routine ultrasound. The most common presenting symptom is painless vaginal bleeding. The absence of an embryo within the gestational sac can be confirmed through serial ultrasound examinations showing no fetal growth or cardiac activity. It is important for healthcare providers to provide appropriate counseling and management options to support the patient through this emotional experience.

Correct Answer: B

Rationale: The type of pregnancy test is not a factor that should be considered by the nurse or the pregnant woman in interpreting the results of a pregnancy test. Factors such as the last menstrual period, previous pregnancy history, and menstrual cycle length play a crucial role in determining the reliability and accuracy of the pregnancy test results.