A postpartum client expresses concern about feeling lightheaded when standing up. What should the nurse prioritize in the assessment to address this issue?

Correct Answer: B

Rationale: Postural hypotension, also known as orthostatic hypotension, is a common issue postpartum and can cause lightheadedness when standing up. When a postpartum client expresses concern about feeling lightheaded, assessing for postural hypotension should be a priority. This assessment involves measuring the client's blood pressure while lying down, sitting, and standing to identify any significant drops in blood pressure upon changing positions. Identifying postural hypotension early allows for appropriate interventions to prevent potential falls and address the client's symptoms. Checking blood pressure, evaluating hemoglobin levels, and monitoring for signs of hemorrhage are also important assessments but may not directly address the specific issue of feeling lightheaded when standing up in this scenario.

Correct Answer: A

Rationale: When a baby is placed on phototherapy, especially for treating jaundice, it is crucial for the nurses to put sunglasses on the newborn to protect their eyes. Phototherapy involves exposing the baby's skin to certain types of light to help break down the bilirubin causing the jaundice. However, this light can be harmful to the baby's sensitive eyes, potentially leading to eye damage or other eye-related issues if not protected adequately. Therefore, placing sunglasses on the newborn is a necessary precaution to ensure the safety and well-being of the baby's eyes during the treatment.

Correct Answer: C

Rationale: The central theme of Sr. Callista Roy's theory is adaptation. Roy's Adaptation Model focuses on the individual's ability to adapt to internal and external stimuli in order to maintain health and well-being. The theory emphasizes the interconnectedness of the individual and their environment, highlighting the dynamic process of adaptation in response to stimuli. By focusing on adaptation, Roy's theory guides nursing practice in promoting holistic care that supports individuals in adapting to changes and achieving optimal health outcomes.

Correct Answer: B

Rationale: The symptoms described—tachycardia, weight loss, and tremors—are consistent with hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism and is an autoimmune disorder in which the thyroid gland is overactive. This condition can lead to an increased production of thyroid hormones, resulting in symptoms such as rapid heartbeat (tachycardia), unintended weight loss, and tremors. In contrast, Hashimoto's thyroiditis is an autoimmune disorder that causes hypothyroidism, leading to symptoms like fatigue, weight gain, and cold intolerance. Diabetes mellitus is a metabolic disorder characterized by high blood sugar levels, which typically presents with symptoms such as increased thirst, frequent urination, and fatigue. Thyroid nodules are growths within the thyroid gland that can sometimes be associated with overactive (hyperthyroidism) or underactive (hypothyroidism) thyroid function, but they do not

Correct Answer: A

Rationale: The presentation described indicates a candidal infection, which commonly occurs in warm, moist body areas like inguinal folds and gluteal cleft. The pruritic, erythematous rash with scaly plaques and satellite papules and pustules is characteristic of cutaneous candidiasis. The recent antibiotic use for urinary tract infection likely disrupted the normal skin flora, predisposing the patient to a Candida overgrowth. Tinea cruris (jock itch) can also present similarly, but the presence of satellite papules and pustules is more indicative of candidiasis. Erythrasma typically presents as well-defined brown-red patches without satellite lesions, and intertrigo is a more generic term referring to inflammation of skin folds that can have various causes, including candidiasis.

Correct Answer: D

Rationale: The causative agent of dengue fever is a virus. Dengue fever is primarily transmitted to humans by the bite of infected Aedes mosquitoes, particularly Aedes aegypti and Aedes albopictus. These mosquitoes act as vectors, carrying and transmitting the dengue virus (specifically four closely related but antigenically different serotypes: DEN-1, DEN-2, DEN-3, and DEN-4) to humans during the feeding process. The virus then replicates in the human body, causing symptoms of dengue fever. Therefore, the correct answer is D. Virus.

Correct Answer: A

Rationale: Immersing oneself in the local community and participating in their everyday activities allows the nurse, as a community organizer, to establish trust and build rapport with the people. By actively engaging with the community members, the nurse can show genuine interest and commitment to their well-being, which fosters a sense of connection and mutual understanding. This approach is crucial for gaining the trust of the community, as it demonstrates that the nurse is invested in listening to their needs and working together to address health concerns effectively.

Correct Answer: B

Rationale: It is crucial for patients with COPD who are prescribed prednisone to be educated about the importance of not abruptly stopping the medication. Prednisone is a type of corticosteroid that should be tapered off gradually under the guidance of a healthcare provider to prevent potential withdrawal symptoms and adrenal insufficiency. Suddenly stopping prednisone can lead to serious adverse effects, including fatigue, weakness, joint pain, fever, dizziness, and potentially life-threatening complications. Therefore, adherence to the prescribed tapering schedule is essential to ensure the safe and effective management of COPD exacerbations with prednisone therapy.

Correct Answer: A

Rationale: The clinical presentation of recurrent episodes of epistaxis, gum bleeding, and easy bruising, along with laboratory findings of prolonged bleeding time, normal platelet count, and normal coagulation studies (PT and aPTT) are highly suggestive of Von Willebrand disease. Von Willebrand disease is the most common inherited bleeding disorder and is characterized by a deficiency or dysfunction of von Willebrand factor (vWF), which plays a key role in platelet adhesion and aggregation. The prolonged bleeding time is due to impaired platelet adhesion to the damaged vessel wall in the absence of functional vWF. Normal platelet count and normal PT/aPTT help differentiate Von Willebrand disease from other bleeding disorders such as hemophilia and platelet function disorders like Glanzmann thrombasthenia and Bernard-Soulier syndrome.