A postpartum client presents with persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?

Correct Answer: C

Rationale: The presence of persistent, severe perineal pain along with ecchymosis and swelling of the perineum can indicate a complication such as a hematoma. A hematoma is a collection of blood that can occur in the perineal area postpartum, usually as a result of trauma during delivery. It is essential to notify the healthcare provider immediately to assess the situation, provide appropriate treatment, and prevent further complications. Applying ice packs or administering additional analgesic medication may not address the underlying issue of a possible hematoma, so prompt medical evaluation is crucial in this situation.

Correct Answer: A

Rationale: When handling information about families in the community, the nurse should consider the principle of confidentiality as ethical. Confidentiality refers to the obligation of healthcare providers to safeguard the privacy of patient information. By maintaining confidentiality, the nurse upholds trust and respect in the nurse-family relationship. This principle ensures that sensitive information shared by families is kept secure and not disclosed without permission, thus respecting their autonomy and promoting open communication in healthcare settings.

Correct Answer: A

Rationale: The appropriate approach of the nurse in this situation would be to talk about the reality of death with the father. It is important to provide appropriate and compassionate communication, acknowledging the father's grief while also gently guiding him towards accepting the reality of the situation. By discussing the reality of death and offering support, the nurse can help the father start the grieving process and eventually come to terms with the loss of his son. It is important to provide emotional support and guidance in a sensitive and respectful manner during such a difficult time.

Correct Answer: A

Rationale: The patient's presentation of episodic throbbing headache associated with nausea, vomiting, sensitivity to light and sound, and aura suggests a diagnosis of migraine headache. Migraines are a common neurological condition characterized by recurrent moderate to severe headaches that are often unilateral, pulsating, and aggravated by physical activity. The presence of premonitory symptoms (aura) before the headache is a key feature commonly seen in migraines. Additionally, nausea, vomiting, and sensitivity to light and sound are also common features associated with migraines.

Correct Answer: B

Rationale: Dupuytren's contracture is a condition characterized by the thickening and tightening of the tissue beneath the skin of the hand, leading to the fingers being pulled into a bent position. One of the common complications associated with Dupuytren's contracture is the development of a Swan-neck deformity. This deformity is characterized by hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint. It is important to recognize and address complications like Swan-neck deformity in individuals with Dupuytren's contracture to prevent further functional impairment and disability.

Correct Answer: A

Rationale: Confirmability is the criteria of trustworthiness that refers to the degree to which the findings of a study are based on the data itself and not on the biases, motivations, or interests of the researchers. In this scenario, returning to the participants to confirm the accuracy of the emerged themes is a way to ensure the confirmability of the study findings. By involving the participants in the validation process, the researchers are seeking to verify that the themes identified truly reflect the experiences of the pregnant women in labor as reported by the participants. This practice enhances the credibility and trustworthiness of the study's findings by confirming their alignment with the participants' perspectives and experiences.

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: A

Rationale: The healthcare team should prioritize performing endoscopic hemostasis with mechanical or thermal techniques in a patient with acute gastrointestinal bleeding (GIB) requiring urgent intervention. This approach involves directly visualizing the bleeding site and applying methods such as clipping, coagulation, or band ligation to stop the bleeding. Endoscopic hemostasis is considered the gold standard for managing acute GIB as it allows for both diagnostic and therapeutic intervention in real-time, offering a targeted and effective way to control bleeding and prevent recurrent episodes. Administering proton pump inhibitors (PPIs) may help in reducing gastric acid secretion and promoting ulcer healing but is not the primary intervention for actively bleeding patients. Implementing strict bed rest may be necessary in some cases to minimize physical exertion, but it is not the primary intervention to manage acute GIB. Transfusion of fresh frozen plasma to correct coagulopathy may be necessary if

Correct Answer: A

Rationale: Neutrophils are a type of white blood cell that play a crucial role in immune defense against pathogens, particularly in phagocytosis - the process by which they engulf and destroy invading microorganisms. In a severe fungal infection, impaired neutrophil function would most likely affect their ability to effectively perform phagocytosis, leading to a compromised immune response against the fungal pathogen. This would result in increased susceptibility to the infection and potentially severe outcomes for the patient. Antibody production, cytokine secretion, and mast cell degranulation are important components of the immune response, but neutrophils are primarily responsible for phagocytosis in the innate immune system.