The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?

Correct Answer: C

Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.

Correct Answer: D

Rationale: The correct answer is D: At a memorial service. This is a safe venue for the nurse to express her feelings of frustration and grief about a patient who has recently died because a memorial service is specifically designed to honor and remember the deceased. It provides a supportive and understanding environment where emotions can be shared openly without judgment. The nurse can find comfort in sharing her feelings with others who have also been impacted by the patient's passing. Incorrect choices: A: In the cafeteria - Not an appropriate setting for expressing personal emotions related to death and dying. B: At a staff meeting - Might not be the most suitable place as the focus is on work-related matters. C: At a social gathering - Not specifically designed for processing grief and may not provide the necessary support and understanding.

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate and comprehensive response to the pregnant patient's question about the risk of her baby being born with HIV. Here's the step-by-step rationale: 1. Option D acknowledges the possibility of the baby contracting HIV at different stages: before, during, or after delivery. This covers all potential scenarios and educates the patient about the risks. 2. By mentioning the different possible transmission times, the nurse highlights the importance of proper prenatal care, delivery planning, and postnatal care to minimize the risk of HIV transmission to the baby. 3. This response empowers the patient with knowledge about the potential risks and emphasizes the importance of seeking appropriate medical interventions to prevent mother-to-child transmission of HIV. 4. In contrast, options A, B, and C provide less informative or inaccurate responses that do not address the patient's concerns adequately, making them incorrect choices. In summary, option D is the best response as it educates the patient about the risks of HIV transmission

Correct Answer: C

Rationale: The correct answer is C: The patient has diabetes. Diabetes can lead to diabetic retinopathy, a common cause of low vision. By knowing the patient's medical history, the nurse can recommend appropriate low vision aids and refer the patient to an ophthalmologist for further evaluation and management. Incorrect choices: A: The patient uses OTC NSAIDs - NSAIDs are not relevant to managing low vision. B: The patient has a history of stroke - A history of stroke is not directly related to low vision. D: The patient has Asian ancestry - Ancestry is not a factor in managing low vision.

Correct Answer: A

Rationale: The correct answer is A because the postpartum patient who has had four saturated pads during the last 12 hours should receive further assessment. This indicates excessive postpartum bleeding (postpartum hemorrhage), which is a critical complication that requires immediate intervention to prevent complications like hypovolemic shock. Monitoring vital signs, assessing for signs of shock, evaluating uterine tone, and determining the cause of bleeding are crucial steps in managing postpartum hemorrhage. Choices B, C, and D are not the correct answers because: B: A patient with Class II heart disease complaining of frequent coughing is more likely experiencing cardiac-related issues and requires evaluation and management by a cardiologist. C: A patient with gestational diabetes and a fasting blood sugar level of 100 mg/dL is within the normal range and does not require immediate further assessment. D: A postcesarean patient with active herpes lesions on the labia requires appropriate management of the herpes infection but does not necess

Correct Answer: D

Rationale: The correct answer is D: Perform gentle massage to stimulate neutrophil migration. Gentle massage helps to promote drainage of the infected area by stimulating neutrophil migration, which aids in fighting the infection. This can help alleviate the pain and discomfort associated with acute mastitis. Cold compresses (choice A) may provide some relief, but they do not address the underlying issue of promoting neutrophil migration. Avoiding washing the breasts (choice C) is not recommended as maintaining good hygiene is important in preventing further infections. Avoiding wearing a bra (choice B) may not directly address the infection and may not be practical for the patient's daily activities.

Correct Answer: A

Rationale: The correct answer is A. Long-term laxative use can lead to the bowel becoming less responsive to stimuli, resulting in constipation. This is due to the body becoming dependent on laxatives to stimulate bowel movements. Choice B is incorrect as laxatives typically do not cause trauma or scarring to the intestinal lining. Choice C is incorrect because while emollient laxatives can be helpful for constipation, long-term use is not recommended due to potential side effects. Choice D is incorrect because laxatives do not directly cause malnourishment or prevent waste production.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Hearing-impaired patient is likely unable to hear during an MRI due to loud noises. 2. Nurse needs to use alternative communication methods like writing or gestures. 3. Sign language interpreter may not be necessary for an MRI. 4. Lip reading may be challenging due to the noisy MRI environment. 5. Interaction should be adapted to accommodate the patient's communication needs.

Correct Answer: A

Rationale: The correct answer is A: Continuous inflow and outflow of irrigation solution. The first lumen inflates the balloon to secure the catheter in place. The second lumen allows continuous inflow of irrigation solution to prevent clot formation. The third lumen allows continuous outflow to ensure the bladder is continuously irrigated. Choices B, C, and D are incorrect because they do not accurately describe the functions of the three lumens in a transurethral resection of the prostate procedure.