Nurse Selma conducts her INITIAL assessment on Catherine. patient keeps on crying and constantly pulls her right ear. What is her MOST APPROPRIATE action?

Correct Answer: D

Rationale: When a patient is crying and continuously pulling at a specific body part, such as Catherine pulling her right ear, it indicates discomfort or pain in that area. Nurse Selma's most appropriate action would be to further assess the description and frequency of the pain. This will help her identify the possible cause of the pain, whether it is due to an ear infection, injury, or any other underlying issue. Understanding the nature and intensity of the pain will guide Nurse Selma in providing appropriate care and intervention for Catherine. It is crucial to address the patient's pain promptly to ensure their comfort and well-being. Referring to the attending physician may be necessary after this initial assessment but assessing the pain should be the immediate priority.

Correct Answer: C

Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.

Correct Answer: B

Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.

Correct Answer: C

Rationale: Anticonvulsant medications, such as phenytoin and phenobarbital, can interfere with pregnancy tests by affecting the levels of human chorionic gonadotropin (hCG) in the body. HCG is the hormone detected in pregnancy tests. These medications may potentially lead to a false-negative result on a pregnancy test for women who are actually pregnant. Therefore, in the case of Almira, who is 6 months pregnant and taking anticonvulsant medication due to the risk of producing a false-negative pregnancy test result, healthcare providers should consider other clinical indicators, such as abdominal cramps and vaginal spotting, to assess her pregnancy status.

Correct Answer: B

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