In the care of patients with communicable diseases, Nurse Keena should know that feces, urine, blood and other body fluids are considered as ______.

Correct Answer: C

Rationale: Feces, urine, blood, and other body fluids are considered as vehicles of transmission in the context of communicable diseases. These substances can carry and transmit disease-causing microorganisms such as bacteria, viruses, and parasites from infected individuals to others. Through close contact or exposure to these contaminated body fluids, the pathogens can enter the body of another person and cause infection. Nurses like Nurse Keena must exercise caution and use appropriate infection control measures to prevent transmission of communicable diseases through these vehicles.

Correct Answer: C

Rationale: The night nurse is expected to collect the patient charts from various departments every three nights. Among the tasks listed, binding the charts as they are is not typically a responsibility of the night nurse. This task is usually handled by administrative staff or professional medical records technicians who are trained to manage the organization and storage of patient charts. The night nurse's primary focus should be on ensuring the correct order of the charts, checking for completeness, and addressing any issues such as torn pages by taping or repairing them to maintain the integrity of the patient records.

Correct Answer: D

Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.

Correct Answer: B

Rationale: Radiologic procedures are typically not used as the least screening assessment by nurses in a perinatal unit. The nurse's initial screening assessments usually focus on gathering information through techniques such as physical examination, interviews, and reviewing laboratory results. Radiologic procedures, such as X-rays or CT scans, are usually ordered by physicians once a more specific diagnostic need has been identified, based on the initial screening assessments performed by the nurse. Therefore, in this scenario, the least screening assessment to be used by the nurse would be radiologic procedures.

Correct Answer: B

Rationale: Urinary incontinence is a common complication associated with prostatectomy for the treatment of benign prostatic hyperplasia (BPH). Prostate surgery, such as a prostatectomy, can disrupt the sphincter muscle that controls the flow of urine from the bladder, leading to temporary or even long-term urinary incontinence in some patients. This usually improves over time with pelvic floor exercises and other treatment options, but it is an important consideration when discussing the potential risks and benefits of prostate surgery with patients. While erectile dysfunction and retrograde ejaculation can also be potential side effects of prostate surgery, urinary incontinence is specifically associated with issues related to bladder control following the procedure. Urethral stricture, although it can occur post prostate surgery, is less common compared to urinary incontinence.

Correct Answer: C

Rationale: The nurse's primary responsibility in responding to a patient's questions about their diagnosis and treatment options is to listen actively and provide accurate, honest, and comprehensive answers. This approach helps build trust between the patient and the healthcare team, allows the patient to make informed decisions about their care, and ensures that the patient understands their condition and the recommended treatment plan. Providing vague answers or ignoring the patient's questions can lead to confusion, anxiety, and mistrust, which can hinder the patient's overall care and recovery. Referring the patient to the physician for all questions may be appropriate for certain medical inquiries, but the nurse plays a crucial role in educating and supporting the patient throughout their healthcare journey.

Correct Answer: D

Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.

Correct Answer: A

Rationale: The most appropriate intervention for managing hepatic encephalopathy in this patient receiving palliative care for end-stage liver disease is to administer lactulose or other ammonia-lowering agents to reduce ammonia levels. Hepatic encephalopathy is believed to be primarily caused by the accumulation of ammonia in the bloodstream due to compromised liver function. Lactulose works by acidifying the gut lumen, which facilitates the excretion of ammonia in the form of ammonium ions. By reducing ammonia levels, hepatic encephalopathy symptoms, such as confusion and altered mental status, can be improved. Initiating other supportive measures like managing precipitating factors, maintaining hydration, and addressing nutritional issues should also be part of the holistic approach in managing hepatic encephalopathy in palliative care. However, addressing the underlying cause by reducing ammonia levels with lactulose is the priority intervention in this scenario.

Correct Answer: B

Rationale: Unilateral neglect is a common condition following a stroke where the individual fails to attend to one side of their body or to the space on that side. In this case, Mang Jose exhibiting signs of unilateral neglect by only shaving one side of his face, neglecting the other side. This behavior demonstrates a lack of awareness or attention to the affected side of his body, indicating a classic symptom of unilateral neglect.