A patient presents with sudden-onset, painless vision loss in the right eye. Fundoscopic examination reveals a cherry-red spot at the macula and attenuated retinal vessels. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: A

Rationale: The patient's presentation of sudden-onset, painless vision loss in the right eye, along with a cherry-red spot at the macula and attenuated retinal vessels, is classic for central retinal artery occlusion (CRAO). In CRAO, there is a sudden blockage of the central retinal artery, leading to ischemia of the retina. The cherry-red spot represents the preserved choroid blood flow against the ischemic retina. The attenuated retinal vessels are a result of decreased blood flow in the retinal circulation. This condition is considered an ophthalmic emergency and requires immediate evaluation and management to prevent permanent vision loss.

Correct Answer: A

Rationale: The nurse in the practice of her profession is guided by a code of ethics, which outlines the moral duties and professional responsibilities of nurses. The code of ethics provides a framework for ethical decision-making and sets standards for professional behavior within the nursing profession. Nurses are expected to adhere to the principles of the code of ethics in order to promote the well-being and safety of their patients, maintain professional integrity, and uphold the values of nursing practice.

Correct Answer: C

Rationale: Postpartum hemorrhage is a serious complication that can occur within the first 24 hours after childbirth. It is the leading cause of maternal mortality worldwide. Therefore, during the immediate postpartum period, the first priority nursing intervention should be focused on observing for signs and symptoms of postpartum hemorrhage, such as excessive bleeding, abnormal vital signs, and changes in uterine tone. Early detection and prompt intervention can prevent severe complications and save the mother's life. Monitoring urinary output, taking vital signs, and checking level of responsiveness are important aspects of postpartum care but observing for postpartum hemorrhage takes precedence due to its critical nature.

Correct Answer: B

Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.

Correct Answer: B

Rationale: Baby Sharon's APGAR score can be determined by assessing five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criteria is given a score of 0, 1, or 2 points, with 2 being the highest score.

Correct Answer: C

Rationale: Bronchoscopy is a procedure that allows direct visualization of the inside of the airways in the lungs. It is considered the most definitive method to establish a diagnosis of lung cancer as it can directly visualize any abnormal growths or tumors in the bronchial tubes. During bronchoscopy, tissue samples can be collected for biopsy to confirm the presence of cancer cells. This procedure is more accurate compared to other diagnostic methods such as chest x-ray, CT scan, cytological study of sputum, or magnetic resonance imaging in confirming a diagnosis of lung cancer.

Correct Answer: D

Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.

Correct Answer: C

Rationale: NSAIDs are known to increase the risk of gastrointestinal complications, particularly gastrointestinal bleeding, ulcers, and perforation. This risk is higher in patients who are elderly, have a history of peptic ulcer disease, are taking high doses of NSAIDs, or are using them for a prolonged period. It is important for the nurse to closely monitor the patient for signs and symptoms of gastrointestinal bleeding, such as abdominal pain, black or tarry stools, vomiting blood, and anemia. Prompt identification and management of these complications are essential to prevent serious consequences. Monitoring for gastrointestinal adverse effects is crucial when a patient is prescribed NSAIDs for managing conditions like osteoarthritis.

Correct Answer: D

Rationale: Postpartum hemorrhage is defined as a blood loss of more than 500 ml within the first 24 hours after vaginal delivery or more than 1000 ml following a cesarean delivery. Excessive bleeding can lead to hypovolemic shock and can be life-threatening if not promptly addressed. Therefore, a blood loss of more than 500 ml/24 hours would lead the nurse to suspect a postpartum hemorrhage and prompt further assessment and intervention.