Nurse Nanie is aware that history taking and physical exam are critical to the diagnostic process and often provide more information than can be gained broad testing strategies. History taking includes the by following, EXCEPT _______

Correct Answer: B

Rationale: Religious Affiliation is not typically included in the history taking process for diagnosing medical conditions. While a patient's religious beliefs may sometimes be relevant in certain situations, it is not a standard component of medical history. History taking usually includes aspects such as the history of present illness, social and family history, and past medical history as these can provide important information related to the patient's health condition.

Correct Answer: A

Rationale: Grilled chicken breast is a suitable choice for a low-phosphorus diet because poultry is typically lower in phosphorus compared to dairy products (like cheese), nuts (like almonds), and whole grains (like wheat toast). This option indicates an understanding of the need to restrict phosphorus intake, which is important for individuals with chronic kidney disease to prevent complications.

Correct Answer: B

Rationale: The appropriate way to correct an error in the Nurses Notes is to draw a single line across the error and initial it. This method is recommended because it indicates that there was an error made, while still preserving the original information for audit and legal purposes. It shows transparency and accountability in documentation, as the original information remains visible. Taking the whole page out and replacing it with a fresh one can lead to discrepancies and potential legal issues if there are inconsistencies in the documentation. Using methods like using the sticky side of the plastic tape or a rubber eraser can make the documentation look unprofessional and raises questions about the accuracy and integrity of the notes.

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: A

Rationale: The appropriate approach of the nurse in this situation would be to talk about the reality of death with the father. It is important to provide appropriate and compassionate communication, acknowledging the father's grief while also gently guiding him towards accepting the reality of the situation. By discussing the reality of death and offering support, the nurse can help the father start the grieving process and eventually come to terms with the loss of his son. It is important to provide emotional support and guidance in a sensitive and respectful manner during such a difficult time.

Correct Answer: A

Rationale: Macrophages are the primary cells responsible for producing tumor necrosis factor-alpha (TNF-α) during the acute phase response. TNF-α is a pro-inflammatory cytokine that plays a critical role in initiating and propagating the inflammatory response. Macrophages secrete TNF-α in response to infection, injury, or other inflammatory stimuli, contributing to the recruitment of immune cells and the activation of additional inflammatory pathways. In the context of the acute phase response, macrophages are key mediators of the immune response and play a crucial role in host defense mechanisms.

Correct Answer: A

Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.

Correct Answer: C

Rationale: The main source of nutrition for the baby during pregnancy is the placenta. The placenta is an organ that develops inside the uterus during pregnancy and provides essential nutrients and oxygen from the mother's blood to the baby through the umbilical cord. It acts as a barrier, protecting the baby from harmful substances while allowing necessary nutrients to pass through. The amniotic fluid serves as a protective cushion for the baby, the uterus provides the space for the baby to grow, and chorionic villi are small, hair-like structures on the placenta that aid in the exchange of nutrients and waste between the mother and the baby. However, the primary source of nutrition for the baby is the placenta, making option C the correct answer in this scenario.

Correct Answer: A

Rationale: The patient with a history of COPD presenting with increased dyspnea, cough productive of purulent sputum, and coarse crackles on auscultation is most likely experiencing an acute exacerbation of COPD. Acute exacerbations in COPD are defined as sustained worsening of the patient's respiratory symptoms beyond normal day-to-day variations, leading to a change in medication. Common triggers for exacerbations include respiratory infections, air pollution, and non-compliance with medications.