Nurse Lyca is aware that testing of vision in infants and children has been treated separately from the testing of adult. which of the statement is NOT true?

Correct Answer: E

Rationale: All of the statements (A-D) are true when discussing the testing of vision in infants and children separately from testing in adults. However, statement E is NOT true. The course of visual and cognitive development MUST be taken into account in evaluating infants and children's visual abilities. It is crucial to consider the stage of development a child is in when evaluating their vision, as their visual abilities can change rapidly during early childhood. Ignoring the course of development could lead to incorrect assessments and misunderstandings about the child's visual capabilities.

Correct Answer: D

Rationale: The presentation described, including a well-demarcated, hyperpigmented patch with irregular borders, asymmetric color distribution, and increase in size over a short period, is concerning for melanoma. Melanoma is a type of skin cancer that arises from melanocytes, the cells that produce pigment in the skin. The irregular borders, color variation, and growth over time are classic signs of melanoma. Melanomas are potentially dangerous and should be evaluated promptly by a healthcare provider for proper diagnosis and treatment. It is important to distinguish melanoma from other benign lesions like melanocytic nevus (mole), lentigo simplex, and seborrheic keratosis, as early detection and treatment of melanoma can significantly impact patient outcomes.

Correct Answer: C

Rationale: In this scenario, the nurse can be sued for malpractice. Malpractice refers to the failure of a professional, in this case, a nurse, to provide the standard of care that a reasonably prudent nurse would have provided in similar circumstances, resulting in harm to the patient. Administering an extra dose of vaccine leading to an adverse reaction and death of the patient is considered a form of medical malpractice as it involves a breach in the standard of care. Generally, malpractice cases involve errors or negligence in the performance of professional duties, which result in harm to the patient.

Correct Answer: B

Rationale: Triangulation is the technique that refers to the use of multiple referents to draw conclusions about what constitutes the truth. In the context provided in the question, Nurse Tarly is organizing a study to investigate the "Caring behavior of Staff-Nurses and Satisfaction of Women with Ostomy". By gathering data from various sources such as observation, interviews, and surveys, Nurse Tarly can triangulate the information to gain a comprehensive understanding of the situation. Triangulation helps to validate findings, enhance the credibility of the study, and provide a more well-rounded view of the issue at hand.

Correct Answer: D

Rationale: Phenazopyridine HCl (Pyridium) is a medication commonly used to relieve the pain, burning, and discomfort associated with urinary tract infections (UTIs). One of the notable side effects of Phenazopyridine is the discoloration of urine, turning it a rusty-red or orange color. This color change is harmless and temporary, but it can be alarming to patients who are unaware of this side effect. Therefore, if a patient undergoing treatment for a UTI notices their urine has turned orange, it is most likely due to the administration of Phenazopyridine.

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: A

Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.

Correct Answer: C

Rationale: The correct response for the nurse in this situation would be to offer the victim a shower after evidence is collected. It is essential to preserve any physical evidence that may be present from the assault during the forensic examination. Allowing the victim to shower before evidence is collected could potentially compromise the evidence and hinder the investigation. The nurse should provide support to the victim during this difficult time and assure them that they will have the opportunity to shower once the necessary evidence is obtained. It is also crucial for the nurse to offer empathy and understanding while explaining the importance of preserving any evidence related to the assault.

Correct Answer: B

Rationale: Benign prostatic hyperplasia (BPH) is a condition characterized by an abnormal enlargement of the prostate gland, which is non-cancerous. This enlargement can lead to lower urinary tract symptoms such as urinary hesitancy (difficulty starting the urine stream), weak urinary stream, incomplete bladder emptying, frequent urination, urgency, and nocturia. BPH is a common condition in aging men and is not usually associated with prostate cancer. Other conditions like prostate cancer, prostatitis, and prostate adenoma may present with similar symptoms, but BPH is specifically characterized by the non-cancerous enlargement of the prostate gland. Treatment for BPH may include medications to improve symptoms or surgical procedures to reduce the size of the prostate gland.