A patient presents with sudden-onset weakness and sensory loss on one side of the body along with difficulty speaking and understanding speech. Imaging reveals an acute infarction involving the right middle cerebral artery territory. Which of the following neurological conditions is most likely responsible for these symptoms?

Correct Answer: C

Rationale: The patient is presenting with sudden-onset weakness and sensory loss on one side of the body along with difficulty speaking and understanding speech, which are classic symptoms of a stroke. The involvement of the right middle cerebral artery territory on imaging suggests an acute infarction, confirming an ischemic stroke. Ischemic stroke occurs due to a blockage or obstruction within a blood vessel supplying blood to the brain, leading to a lack of oxygen and nutrients reaching brain tissue. This results in neurological deficits corresponding to the affected area of the brain. In contrast, a transient ischemic attack (TIA) would present with similar symptoms but resolve within 24 hours without evidence of acute infarction on imaging. Intracerebral hemorrhage and subarachnoid hemorrhage involve bleeding into the brain tissue or the space surrounding the brain, respectively, resulting in different clinical presentations.

Correct Answer: C

Rationale: The appropriate initial management for a conscious patient experiencing a syncopal episode (fainting) is to provide reassurance and assist the patient to a lying position. This is important to ensure adequate blood flow to the brain and to prevent further injury in case the patient faints again. Elevating the legs above the level of the heart is not recommended as a routine intervention for syncope. Administering intravenous fluids rapidly is not usually needed in the initial management of syncope without signs of dehydration or significant bleeding. Administering oxygen via nasal cannula is not necessary for most cases of syncope unless there are specific indications such as signs of respiratory distress.

Correct Answer: C

Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.

Correct Answer: D

Rationale: The most likely cause of the sudden onset of severe abdominal pain and dark red vaginal bleeding with a tender, firm uterus at 28 weeks gestation is abruptio placentae. Abruptio placentae, also known as placental abruption, is the premature separation of the placenta from the uterine wall before delivery. This condition can be life-threatening to both the mother and the fetus, as it can lead to severe bleeding and compromise the oxygen and nutrients supply to the fetus. The presentation typically includes severe abdominal pain, dark red or maroon vaginal bleeding, uterine tenderness, and a firm uterus due to the blood accumulation behind the placenta. Prompt recognition and intervention are crucial to prevent adverse maternal and fetal outcomes.

Correct Answer: B

Rationale: In this scenario, the patient is presenting with acute exacerbation of chronic heart failure (CHF) complicated by pulmonary edema and respiratory distress. The priority intervention for managing this exacerbation is to initiate positive pressure ventilation for respiratory support. Positive pressure ventilation, such as non-invasive positive pressure ventilation (NIPPV) or invasive mechanical ventilation, can help improve oxygenation and decrease the work of breathing for the patient. By providing adequate respiratory support, ventilation can reduce the negative effects of pulmonary edema and respiratory distress due to CHF exacerbation. Administering intravenous loop diuretics (Choice A) might be necessary to address fluid overload, but it is not the initial priority as ensuring adequate ventilation is crucial. Emergent pericardiocentesis (Choice C) is not indicated in this scenario as there is no mention of cardiac tamponade. Inotropic medications (Choice D) may be considered in managing acute exacerbation of CHF but

Correct Answer: A

Rationale: Option A is the most appropriate nursing intervention to facilitate effective communication with the 80-year-old male patient. This approach involves waiting for the patient to be fully awake before discussing important information about the surgery and potential post-surgery events with both the patient and family. This allows the patient to fully comprehend the information provided and ask any necessary questions. Effective communication is crucial in promoting patient understanding and cooperation, especially in older adults who may require additional time to process information due to factors such as age-related cognitive changes. It is important to ensure that the patient receives clear and accurate information to support their recovery process and reduce anxiety.

Correct Answer: A

Rationale: The purpose of asking Nurse Rosie to submit an Incident Report (IR) is most likely to note patterns of incidences in the same unit. Incident reports are essential tools in healthcare settings to track and analyze unexpected events, errors, or situations that may impact patient care and safety. By collecting and reviewing incident reports, the head nurse can identify trends, patterns, or commonalities in the occurrences within the unit. This information allows for targeted interventions, improvements in practices, and enhanced patient safety. Therefore, asking Nurse Rosie to submit an IR would serve the purpose of noting patterns of incidences in the same unit for proactive and quality care delivery.

Correct Answer: B

Rationale: The presence of risk factors indicates an increased likelihood or susceptibility to developing a particular disease. While risk modification and healthy lifestyle choices can help reduce the risk, having these risk factors still increases the overall chances of getting the disease compared to individuals without the same risk factors. It is essential for individuals with risk factors to be proactive in managing their health to mitigate the increased risk.

Correct Answer: A

Rationale: Proper latch technique is the most important nursing intervention to alleviate nipple soreness in a breastfeeding client. When a baby latches on correctly, it helps prevent nipple trauma and soreness. Educating the client on how to achieve a proper latch, such as ensuring the baby's mouth covers both the nipple and areola, can significantly reduce discomfort during feedings. Improving the latch can also enhance milk transfer, leading to better breastfeeding outcomes for both the mother and baby. While lanolin cream (choice C) can provide some relief for sore nipples, addressing the root cause by correcting the latch is crucial for long-term comfort and successful breastfeeding. Using nipple shields (choice B) or encouraging the use of breast pumps (choice D) should not be the first line of intervention when addressing sore nipples, as they do not address the underlying issue of latch technique.