A patient with a history of chronic liver disease presents with jaundice, ascites, and spider angiomas. Laboratory tests reveal elevated serum bilirubin levels, prolonged prothrombin time, and hypoalbuminemia. Which condition is the patient most likely experiencing?

Correct Answer: C

Rationale: The patient's presentation of jaundice, ascites, spider angiomas, elevated serum bilirubin levels, prolonged prothrombin time, and hypoalbuminemia are all indicative of cirrhosis. Cirrhosis is a late stage of liver disease characterized by liver scarring and poor liver function. Jaundice, which is the yellowing of the skin and eyes due to elevated bilirubin levels, is a common manifestation of liver dysfunction seen in cirrhosis. Ascites, the accumulation of fluid in the abdomen, is also a common complication of cirrhosis. Spider angiomas, which are small blood vessels near the skin's surface, are a result of altered blood flow in the liver due to cirrhosis. Prolonged prothrombin time and hypoalbuminemia are consequences of reduced liver synthesis function in cirrhosis. Hepatic encephalopathy and hepatorenal syndrome

Correct Answer: C

Rationale: The nurse should always keep Tensilon (Edrophonium) at the bedside of a client with myasthenia gravis. Tensilon is a fast-acting cholinesterase inhibitor that can be used for the diagnosis and emergency treatment of myasthenia crisis. It helps improve muscle strength temporarily by increasing the levels of acetylcholine at the neuromuscular junction. Administering Tensilon can help differentiate between a myasthenic crisis (marked improvement in muscle strength) and a cholinergic crisis (no improvement or worsening of muscle weakness). Keeping Tensilon at the bedside allows for prompt administration in case of a myasthenic crisis.

Correct Answer: B

Rationale: When a patient is diagnosed with pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would typically include fine crackles. Fine crackles are discontinuous, high-pitched crackling or rattling sounds heard during inspiration that indicate the presence of fluid in the small airways or alveoli. These crackles are caused by the movement of secretions or exudate within the bronchioles or alveoli, which is a common characteristic of pneumonia. Wheezing sounds are usually associated with conditions such as asthma, bronchitis, or COPD and are caused by narrowed airways. Stridor is a high-pitched, crowing sound that typically indicates an obstruction in the upper airway and is often heard in cases of laryngeal inflammation or foreign body aspiration. Deep and low-pitched breath sounds are more characteristic of conditions like chronic bronchitis.

Correct Answer: C

Rationale: Incident Reports (IRs) must be summarized monthly and stored in a secured cabinet for several reasons. Firstly, summarizing the IRs monthly allows for a consolidated overview of the incidents that have occurred, highlighting any recurring patterns or trends that may need to be addressed. By storing the summarized IRs in a secured cabinet, the information is kept confidential and protected from unauthorized access. This practice also ensures that the reports are organized and easily accessible for future reference or audits. Storing the IRs on an open cabinet, table top, or with a classification system that may not be easily understandable can lead to potential breaches of confidentiality or difficulty in retrieving and understanding the information when needed.

Correct Answer: A

Rationale: Hashimoto's thyroiditis is an autoimmune disorder characterized by chronic inflammation of the thyroid gland. In this condition, lymphocytic infiltration and germinal centers can be seen in the thyroid tissue. This inflammation can lead to the formation of thyroid nodules and enlargement of the thyroid gland, causing symptoms such as difficulty swallowing and breathing due to compression of surrounding structures. Additionally, Hashimoto's thyroiditis can result in hypothyroidism over time, further contributing to the symptoms. Therefore, the patient in this case is most likely experiencing these symptoms due to Hashimoto's thyroiditis. Graves' disease, on the other hand, typically presents with hyperthyroidism and is less likely to manifest as compressive symptoms of the thyroid gland.

Correct Answer: B

Rationale: Creating a conducive time and place for the teachings is crucial during the implementation process to ensure better assimilation by the staff. By choosing a suitable time that does not clash with other responsibilities and providing a comfortable environment for learning, the nurse can enhance the staff's understanding and retention of the teachings. This approach helps in engaging the staff effectively and facilitating a productive learning experience.

Correct Answer: A

Rationale: Educating the client about the importance of balanced nutrition and frequent monitoring of blood glucose levels should be prioritized to address the client's concerns about managing blood sugar levels while breastfeeding. This intervention helps empower the client to make informed choices about her diet and monitor her blood sugar levels effectively. By focusing on balanced nutrition and regular blood glucose monitoring, the client can better manage her blood sugar levels during the postpartum period and while breastfeeding, reducing the risk of complications associated with gestational diabetes. It also promotes overall health and well-being for both the mother and the baby.

Correct Answer: C

Rationale: To create personal time as a nurse with rotating shifts, it is important to prioritize personal well-being and make time for oneself. By eliminating tasks that add no value, nurses can streamline their workload and focus on essential responsibilities. This can help in reducing unnecessary stress and allowing for more personal time outside of work. Delegating work to others and filling every moment with tasks or chores may not necessarily create personal time, as it can keep nurses constantly busy and overwhelmed. Hiring someone else to do the work may not always be feasible or practical in a nursing setting, but by eliminating non-essential tasks, nurses can better manage their time and have more opportunities for personal activities and self-care.

Correct Answer: D

Rationale: If a nurse notices a discrepancy between the surgical count and the number of instruments on the sterile field during surgery, it is crucial to inform the surgical team immediately and initiate a thorough search. Patient safety is of utmost importance, and any missing instruments could potentially pose a risk to the patient. By informing the team and conducting a thorough search, the missing instrument can be located promptly to ensure it is not inadvertently left inside the patient's body. Continuing with the procedure or ignoring the discrepancy without further investigation could lead to serious consequences for the patient's well-being. It is always better to address any discrepancies or concerns during surgery proactively to maintain a high standard of patient care and safety.