Following a severe traumatic brain injury, a patient is experiencing alterations in consciousness characterized by periods of wakefulness but with no meaningful interaction with the environment. Which term best describes this state?

Correct Answer: B

Rationale: A vegetative state, now more commonly referred to as unresponsive wakefulness syndrome, describes a condition where the patient is awake but with no awareness of themselves or their surroundings. This state usually follows a severe brain injury, such as traumatic brain injury. Patients in a vegetative state may have sleep-wake cycles, open their eyes, and even exhibit reflex movements, but they do not demonstrate any meaningful interaction with the environment. Differentiating between coma and vegetative state is important, as coma implies a complete lack of consciousness, while patients in a vegetative state have preserved wakefulness without awareness. Minimally conscious state (choice C) refers to a condition where there are some minimal signs of awareness or purposeful interaction, making it a different state than the one described in the scenario. Locked-in syndrome (choice D) is a condition where the patient is conscious and aware but unable to move or communicate due to paralysis, which is not consistent

Correct Answer: A

Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.

Correct Answer: D

Rationale: The primary purpose of a pregnancy test is to confirm whether a woman is pregnant or not. Once pregnancy is confirmed, it is crucial for the individual to begin prenatal care as early as possible to ensure a healthy pregnancy and delivery. Early initiation of care can help monitor the health of both the mother and the developing fetus, detect any potential issues or complications early on, and provide necessary interventions or treatments. Therefore, the main objective of a pregnancy test is to enable early initiation of care for the pregnant individual.

Correct Answer: C

Rationale: Conducting a year-end performance evaluation of the staff is an example of a controlling function in management. Controlling involves monitoring and evaluating the performance of employees to ensure that they are working effectively and meeting the set goals and standards. By assessing the staff's performance at the end of the year, managers can identify areas of improvement, provide feedback, and make necessary adjustments to ensure the overall success of the organization. Hence, the process of evaluating staff performance falls under the controlling function of management.

Correct Answer: B

Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.

Correct Answer: A

Rationale: In a patient with acute myocardial infarction (MI) presenting with ST-segment elevation on ECG, the healthcare team should prioritize performing emergent coronary angiography for revascularization. This intervention, also known as primary percutaneous coronary intervention (PCI), involves opening up the blocked coronary artery responsible for the MI. Timely reperfusion of the affected artery is crucial in reducing myocardial damage and improving outcomes in acute MI patients. PCI is considered the preferred method for revascularization in patients with ST-segment elevation MI, as it has been shown to be more effective and associated with better outcomes compared to fibrinolytic therapy.

Correct Answer: C

Rationale: The pancreas is the structure responsible for producing digestive enzymes and bicarbonate-rich pancreatic juice. These enzymes aid in the breakdown of carbohydrates, fats, and proteins in the small intestine to facilitate the absorption of nutrients. The pancreas plays a crucial role in the process of digestion, making it an essential organ in the digestive system. The liver is primarily involved in producing bile to aid in the digestion of fats, the gallbladder stores bile produced by the liver, and the spleen is involved in filtering the blood and storing blood cells.

Correct Answer: B

Rationale: The patient's presentation with renal failure, confusion, seizures, asterixis, and a sweet odor to the breath, along with laboratory findings of severe metabolic acidosis, hyperkalemia, and elevated BUN and creatinine levels, is consistent with uremic encephalopathy. Uremic encephalopathy is a neurological complication of acute or chronic renal failure resulting from the buildup of uremic toxins in the blood, leading to various neurological symptoms such as confusion and seizures. The sweet odor to the breath can be attributed to the presence of urea, a waste product that accumulates in renal failure. Other metabolic abnormalities like hyperkalemia and severe metabolic acidosis are also common in renal failure. It is crucial to promptly recognize and manage uremic encephalopathy to prevent further neurological complications.

Correct Answer: C

Rationale: The analytic approach refers to a method that views factors that influence health and by which interventions to improve health are directed. In this case, utilizing an analytic approach in the research means looking into the root causes of the health problems in the community, analyzing various factors that contribute to the prevalence of obesity and heart ailments, and developing targeted interventions to address these issues effectively. This approach involves identifying underlying reasons for health problems and strategically planning interventions to improve the health outcomes of the community.