A patient with a suspected spinal injury is found unconscious. Which of the following actions should be taken first?

Correct Answer: B

Rationale: When a patient with a suspected spinal injury is found unconscious, the priority action is to secure the airway without jeopardizing the cervical spine. A jaw thrust maneuver is the appropriate technique to open the airway in this situation because it allows for the maintenance of neutral alignment of the cervical spine while ensuring proper ventilation. Moving the patient to a flat surface or applying a cervical collar could potentially worsen the spinal injury if not done correctly, and checking for responsiveness should only be done after ensuring a patent airway. Therefore, the safest and most effective initial action is to perform a jaw thrust maneuver to establish a clear airway.

Correct Answer: D

Rationale: During the active phase of labor, a cervical dilation of 6 cm and regular contractions lasting 60 seconds each, occurring every 3 minutes indicate good progress in labor. The nurse should continue to monitor the progress closely by assessing the mother's vital signs, fetal heart rate, and the pattern of contractions. It is important to provide support and encouragement to the mother, continue with comfort measures, and be prepared to assist with the delivery when the cervix is fully dilated. This stage of labor is focused on active dilation and effacement of the cervix, and it is not yet time for the mother to push or for the nurse to administer oxytocin to augment labor.

Correct Answer: E

Rationale: All of the statements (A-D) are true when discussing the testing of vision in infants and children separately from testing in adults. However, statement E is NOT true. The course of visual and cognitive development MUST be taken into account in evaluating infants and children's visual abilities. It is crucial to consider the stage of development a child is in when evaluating their vision, as their visual abilities can change rapidly during early childhood. Ignoring the course of development could lead to incorrect assessments and misunderstandings about the child's visual capabilities.

Correct Answer: B

Rationale: A severe headache is a classic sign of a hemorrhagic stroke. Hemorrhagic stroke occurs when a blood vessel in the brain ruptures and causes bleeding. This bleeding can lead to increased pressure within the skull, resulting in a sudden and severe headache. Other symptoms of a hemorrhagic stroke may include nausea, vomiting, sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, and loss of coordination. It is important to seek immediate medical attention if someone is experiencing symptoms of a stroke, including a severe headache, as prompt treatment is crucial in minimizing damage and improving outcomes.

Correct Answer: C

Rationale: The barrier to goal setting between the nurse and the family in this scenario is the failure of the family to perceive the existence of the problem. Goal setting in healthcare generally requires mutual agreement and understanding between the healthcare provider (nurse) and the patient/family. If the family does not perceive that there is an existing problem that needs to be addressed, there will likely be resistance or lack of motivation to set goals and work towards resolving the issue. This barrier can hinder effective communication, collaboration, and ultimately, the successful achievement of healthcare goals. It is important for the nurse to address this barrier through education, communication, and building trust to ensure that all parties are on the same page and actively participate in goal setting and care planning.

Correct Answer: A

Rationale: Macrophages are the primary cells responsible for producing tumor necrosis factor-alpha (TNF-α) during the acute phase response. TNF-α is a pro-inflammatory cytokine that plays a critical role in initiating and propagating the inflammatory response. Macrophages secrete TNF-α in response to infection, injury, or other inflammatory stimuli, contributing to the recruitment of immune cells and the activation of additional inflammatory pathways. In the context of the acute phase response, macrophages are key mediators of the immune response and play a crucial role in host defense mechanisms.

Correct Answer: D

Rationale: The most common symptom of scabies that the family would report to Nurse Emma is itchiness. Scabies is a contagious skin condition caused by the Sarcoptes scabiei mite, which burrows into the skin and lays eggs, leading to intense itching, especially at night. The itching is a result of the body's allergic reaction to the mites and their waste products. While rashes, scaling, and swelling can also occur with scabies, the hallmark and most bothersome symptom experienced by individuals with scabies is the intense itchiness, making it the most common symptom reported by affected individuals or their families during the history-taking process.

Correct Answer: B

Rationale: In this scenario, the firm and midline fundus at three hours postpartum indicates that the uterus is contracting well. The presence of a small constant trickle of blood on perineal inspection suggests ongoing bleeding. This combination of findings is concerning for retained placenta, where a portion of the placenta remains attached to the uterine wall and prevents proper contraction and closure of the blood vessels at the placental site. Retained placenta can lead to postpartum hemorrhage and requires prompt evaluation and intervention to prevent complications. Nurse Kayla should escalate this finding to the healthcare provider for further assessment and management.

Correct Answer: D

Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.