Lillian asks the nurse the cause of this ailment. Which of the following would the nurse explain as predisposing factors of mastitis? (Select all that apply) I. Milk stasis II. Nipple trauma III. Using alcohol in cleaning nipples IV. Baby 's sitting position

Correct Answer: B

Rationale: Mastitis is typically caused by bacterial infection, with predisposing factors including milk stasis (I) and nipple trauma (II). Milk stasis occurs when milk is not effectively removed from the breast, leading to a build-up that can block ducts and predispose to infection. Nipple trauma, such as cracks or damage, can provide entry points for bacteria to infect the breast tissue. Factors like using alcohol in cleaning nipples (III) and the baby's sitting position (IV) are not directly associated with the development of mastitis.

Correct Answer: D

Rationale: The bio-ethical principle of veracity pertains to honesty and truthfulness in healthcare communication. By providing fraudulent information about the patient's diagnosis and prognosis, the nurse would be violating the principle of veracity. It is crucial for healthcare providers to be honest and provide accurate information to patients in order to ensure informed decision-making and uphold the trust between healthcare professionals and their patients. Misleading a patient about their diagnosis and prognosis can have serious consequences on the patient's understanding of their condition, treatment decisions, and overall well-being. Therefore, maintaining honesty and truthfulness is essential in promoting ethical healthcare practices.

Correct Answer: A

Rationale: Selective IgA deficiency is a primary immunodeficiency disorder characterized by low or absent levels of immunoglobulin A (IgA) in the blood. Since IgA plays a crucial role in mucosal immunity and defense against pathogens at mucosal surfaces, individuals with this deficiency are more susceptible to recurrent bacterial infections, particularly of the respiratory and gastrointestinal tracts. In contrast, severe combined immunodeficiency (SCID) is a more severe immunodeficiency disorder affecting T and B lymphocytes, chronic granulomatous disease (CGD) is a disorder of phagocytes, and autoimmune hemolytic anemia is an autoimmune disease involving red blood cells, none of which are directly associated with selective IgA deficiency.

Correct Answer: C

Rationale: Nurse Sandra should consider Cindy, 7 years old who has been absent due to skin lesions, as a priority for home visitation. Skin lesions can indicate potential health issues that need to be addressed promptly. Cindy's frequent absences could be a sign that her condition is affecting her school attendance and overall well-being. By conducting a home visit, Nurse Sandra can assess Cindy's living environment, provide appropriate care recommendations, and ensure that she receives necessary medical attention. This proactive approach can help address Cindy's health concerns and support her academic performance.

Correct Answer: D

Rationale: Respiratory depression resulting from drug overdose typically leads to a decrease in the respiratory rate, known as bradypnea. This is characterized by abnormally slow breathing, which can be dangerous as it may lead to decreased oxygen levels in the blood. Bradypnea indicates a slowing down of the respiratory drive, in contrast to hyperventilation, biot's respiration, or tachypnea. It is crucial for the nurse to monitor a patient experiencing respiratory depression for signs of bradypnea and intervene promptly to prevent further complications.

Correct Answer: B

Rationale: Nurse Florence needs to attain a certain number of continuing Professional Development units in order to renew her Professional License. Continuing Professional Development ensures that nurses stay up-to-date with the latest advancements and best practices in the field, ultimately leading to improved patient care outcomes. Renewing the Professional License is crucial for Nurse Florence to legally practice nursing and demonstrate her commitment to ongoing learning and development in the profession.

Correct Answer: B

Rationale: The most appropriate nursing diagnosis for the individual described is "Ineffective individual coping." This is because the individual has been facing challenges in both academic (failing math class) and personal (substance dependence) aspects of his life. The repeated failures in his math class and the substance dependence for three years indicate that he might be struggling to cope with stressors and challenges in his life effectively. By identifying this nursing diagnosis, the nurse can focus on helping the individual develop effective coping strategies to manage and overcome these difficulties.

Correct Answer: B

Rationale: When managing a conscious patient with a severe nosebleed (epistaxis), the appropriate intervention is to have the patient sit upright and lean slightly forward to prevent blood from flowing into the throat and causing choking or swallowing. Pinching the soft part of the nose just below the bony part can help apply pressure to the bleeding vessel and stop the bleeding. This maneuver also helps compress the blood vessels in the nose, promoting clot formation and stopping the bleeding. It is important not to tilt the head back as this can cause blood to flow into the throat and potentially lead to swallowing, choking, or aspiration. Packing the nose with cotton gauze should be done by medical professionals if the bleeding does not stop with direct pressure. Applying direct pressure to the forehead is not effective for managing nosebleeds; pressure should be applied to the nostrils instead.

Correct Answer: A

Rationale: Tricyclic antidepressants (TCAs) are known to have anticholinergic effects, which can lead to various cardiovascular side effects, including orthostatic hypotension, tachycardia, and potential hypertension. While hypotension is a possible adverse effect, hypertension is more commonly associated with TCAs. Therefore, it is essential for the nurse to monitor the patient for signs of hypertension, such as elevated blood pressure readings, to prevent any adverse outcomes and ensure the patient's safety while on this medication.