During theh history taking, which of the following is the MOST common symptom of Scabies that the family would report to Nurse Emma?

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: A

Rationale: The BEST position for a patient in shock is the modified Trendelenburg position. In this position, the patient's legs are elevated above the level of the heart to enhance blood flow back to the heart and vital organs. Placing the patient in the modified Trendelenburg position helps increase venous return, improves cardiac output, and promotes perfusion to vital organs, which can be crucial in managing shock. This position can help stabilize the patient's condition while awaiting further medical intervention.

Correct Answer: A

Rationale: Checking the flow of oxygen is the priority action because it ensures that Sonny is receiving the correct amount of oxygen prescribed by the healthcare provider. Before connecting the flow meter to the oxygen outlet, turning on the oxygen, or attaching the humidifier, it is crucial to verify that the flow rate is appropriate for Sonny's condition. Monitoring and adjusting the oxygen flow will help maintain the desired oxygen saturation levels and prevent potential complications related to oxygen therapy.

Correct Answer: B

Rationale: Nurse Chona should explain to Patient Noel that the sign of negative before the word means that he is not drinking alcohol or smoking cigarettes. This is a simple misunderstanding and clarification should help clear up any confusion. It is important to uphold patient confidentiality and respect their autonomy, rather than reprimanding the patient for looking at their own chart. It is also essential to address any discrepancies in the patient's medical record to ensure accurate information is documented for proper treatment and care.

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: Pemoline (Cylert) is a central nervous system stimulant used in the treatment of ADHD. One of the significant potential side effects of pemoline is hepatotoxicity, which can manifest as elevated liver function test results. Therefore, the nurse must monitor the patient's liver function regularly while they are taking pemoline to monitor for any signs of liver damage or dysfunction. It is essential to educate the patient about the signs and symptoms of liver problems, such as jaundice (yellowing of the skin or eyes), abdominal pain, nausea, or dark urine, and to report any such symptoms immediately to their healthcare provider. Regular monitoring and early detection of liver function abnormalities can help prevent severe liver damage in patients taking pemoline.

Correct Answer: B

Rationale: Delegation by succession involves passing on responsibility and authority to a designated successor when the delegator is temporarily unavailable. In this scenario, the unit manager is planning to take her regular official business leave and has recommended her assistant unit manager to assume her position during her absence. This act follows the principle of succession, where the deputy or next in line is entrusted with the duties and decision-making power of the manager. This ensures a smooth transition of responsibilities and allows the operations to continue efficiently in the manager's absence.

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: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.