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: C

Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.

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.

Correct Answer: B

Rationale: One of the signs and symptoms of Benign Prostatic Hyperplasia (BPH) is not pain on urination. BPH is a non-cancerous enlargement of the prostate gland which can cause urinary symptoms such as frequency of urination, dribbling of urine, hesitancy in starting urination, weak urine flow, feeling of incomplete bladder emptying, and increased urination at night (nocturia). Pain on urination is not typically associated with BPH, and it may suggest other urinary tract issues such as a urinary tract infection or a different medical condition.

Correct Answer: B

Rationale: Administering pain relief medication as ordered is the best action for the nurse to take in this situation where the patient is experiencing intense pain during irregular and short uterine contractions. Pain relief medications can help alleviate the discomfort and distress that Ellie is experiencing, providing her with much-needed relief and improving her overall comfort during labor. It is important for the nurse to follow the prescribed orders for pain relief medication to ensure safe and effective pain management for the patient.

Correct Answer: A

Rationale: The liver is responsible for secreting bile, which aids in the emulsification and digestion of fats. Bile is produced by the liver and is stored and concentrated in the gallbladder before being released into the small intestine to help with the breakdown of fats during the digestion process. The gallbladder functions as a storage organ for bile produced by the liver. The pancreas secretes digestive enzymes and bicarbonate to aid in the digestion process, while the spleen is mainly involved in immune function and blood storage.

Correct Answer: B

Rationale: Supplying the patient with paper tissues to use when touching doorknobs is the most appropriate response in this situation. This action acknowledges and respects the patient's anxiety while providing a practical solution to help her cope. Forcing her to touch doorknobs or discouraging her concerns would not address the underlying anxiety and may lead to increased distress. Encouraging her to scrub doorknobs with a strong antiseptic is not necessary and may exacerbate her anxiety. Explaining that her concerns are part of her illness may invalidate her feelings and is not a constructive way to address the situation. Supplying her with paper tissues allows her to feel more comfortable while still being able to navigate her daily activities.

Correct Answer: C

Rationale: Osteoporosis is a condition characterized by an imbalance between bone resorption (breakdown of bone tissue) and bone formation, leading to bone thinning and increased risk of fractures. In osteoporosis, bones become weak and porous, making them more prone to fractures even with minor trauma. This condition is common in postmenopausal women and older individuals. Risk factors for osteoporosis include age, gender, family history, lack of physical activity, low calcium and vitamin D intake, smoking, excessive alcohol consumption, and certain medications. Treatment typically involves lifestyle modifications, including adequate calcium and vitamin D intake, weight-bearing exercises, and sometimes medication to help slow down bone loss and reduce fracture risk. Early detection and management of osteoporosis are crucial to prevent fractures and maintain bone health.

Correct Answer: B

Rationale: Beta-blockers work by blocking the effects of adrenaline on beta receptors in the body. One common adverse effect of beta-blockers is bradycardia, or a slowed heart rate. Since the patient is being prescribed a beta-blocker for migraine headaches, it is important for the nurse to monitor closely for signs and symptoms of bradycardia such as dizziness, fatigue, and fainting. Monitoring the heart rate regularly and reporting any significant decrease to the healthcare provider is essential to prevent complications associated with bradycardia. Compared to the other options, bradycardia is the most relevant adverse effect to monitor in a patient prescribed a beta-blocker.