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: B

Rationale: Leaving the side rails down is one of the most common occurrences that can lead to a patient fall. Side rails are important safety measures designed to prevent patients from falling out of bed. When the side rails are left down, the patient is at a higher risk of accidentally rolling out of bed and falling. It is crucial for healthcare providers to always ensure that the side rails are up and secure to help prevent patient falls.

Correct Answer: D

Rationale: The patient is presenting with symptoms and laboratory findings consistent with a paraneoplastic syndrome related to Hodgkin lymphoma. In this case, the fever, chills, generalized malaise, pancytopenia, circulating Reed-Sternberg cells, and bone marrow involvement are all indicative of a paraneoplastic syndrome associated with Hodgkin lymphoma. Paraneoplastic syndromes are a group of disorders that are triggered by an abnormal immune response to a neoplasm, such as Hodgkin lymphoma, leading to various systemic manifestations.

Correct Answer: C

Rationale: It is not important for Myra to listen to the tape recordings only when she feels motivated or productive. In a nurse-patient interaction relationship, listening to tape recordings promptly (Choice A) is crucial because it ensures that any important information or cues are not missed or forgotten. Additionally, noting voice tone and inflection (Choice B) and observing pauses (Choice D) are essential for understanding the nuances and emotions conveyed during the interaction, which can be crucial in effective communication. Listening based on motivation may lead to delays and hamper the timely analysis and understanding of the interactions. Hence, it is important for Myra to prioritize active and focused listening to the tape recordings, regardless of her current motivation levels.

Correct Answer: A

Rationale: Qualitative research data are typically in text form rather than numeric or statistical data. This means that the data collected through qualitative research methods are descriptive and usually presented in the form of words, phrases, or narratives. Qualitative data often involve subjective interpretations, opinions, and in-depth insights, making text a more suitable format for capturing these nuances compared to numerical or quantitative data. The focus in qualitative research is on understanding experiences, meanings, and perspectives, which are best conveyed through textual data.

Correct Answer: A

Rationale: In a patient with acute myocardial infarction (MI) presenting with ST-segment elevation on ECG, the healthcare team should prioritize performing emergent coronary angiography for revascularization. This intervention, also known as primary percutaneous coronary intervention (PCI), involves opening up the blocked coronary artery responsible for the MI. Timely reperfusion of the affected artery is crucial in reducing myocardial damage and improving outcomes in acute MI patients. PCI is considered the preferred method for revascularization in patients with ST-segment elevation MI, as it has been shown to be more effective and associated with better outcomes compared to fibrinolytic therapy.

Correct Answer: C

Rationale: When a postpartum client exhibits signs of wound infection, such as erythema, warmth, and purulent drainage from a cesarean incision, it is essential to notify the healthcare provider immediately. Wound infections can lead to serious complications if not promptly addressed. The healthcare provider will assess the infection, possibly order further diagnostic tests, and determine the appropriate course of treatment, which may include antibiotics or additional wound care measures. Applying a dressing or irrigating the wound may be part of the treatment plan prescribed by the healthcare provider, but the first step is always to seek guidance from the provider.

Correct Answer: C

Rationale: Uterine rupture is a serious obstetric emergency that involves a tear or rupture of the uterine wall during pregnancy. In this scenario, the pregnant woman with severe lower abdominal pain, vaginal bleeding, and a tender, distended abdomen is showing signs consistent with uterine rupture. These symptoms are typically not seen with other conditions listed.

Correct Answer: B

Rationale: Record-keeping is not an optional task; it is a critical aspect of professional nursing practice. As a nurse, maintaining accurate and timely records is essential for providing quality care, ensuring legal and ethical standards are met, and promoting patient safety. Failure to keep thorough records can lead to serious consequences such as compromising patient care, violating regulations, and even facing legal consequences. Thus, record-keeping should be seen as a mandatory part of the professional duty of nurses rather than an optional task that can be done when circumstances allow.