The nurse knows that the diagnosis of contact latex allergy is based on history and ____.

Correct Answer: C

Rationale: The diagnosis of contact latex allergy is primarily based on the patient's history of exposure to latex-containing products and the development of symptoms upon contact with latex. To confirm the diagnosis, skin patch testing is performed. Skin patch testing exposes the skin to small amounts of latex allergens to observe for any localized allergic reaction, such as redness, swelling, or itchiness. This test helps determine if the individual has developed a delayed-type hypersensitivity reaction to latex. Latex-specific IgE testing (choice A) and finding IgE in serum (choice B) are methods used in diagnosing immediate-type latex allergy but are not sufficient for confirming contact latex allergy specifically. ELISA (choice D) is a type of laboratory technique used for various purposes, including measuring the levels of specific substances in the blood, but it is not typically used as a diagnostic tool for contact latex allergy.

Correct Answer: C

Rationale: In assigning rooms for the injured patients, the most appropriate and compassionate choice is to have mother and child together in one room. This decision prioritizes the well-being and emotional support for the child, as having the mother nearby can have a positive impact on the child's recovery. It also promotes family bonding during a difficult time, which can aid in the healing process. Additionally, the presence of a parent can provide comfort and reassurance to the child, contributing to a more positive hospital experience. Therefore, it is important for the nurses to coordinate with the Administration to ensure that mother and child are assigned to the same room whenever possible.

Correct Answer: C

Rationale: Maintaining patient confidentiality is a foundational principle in healthcare ethics. Nurses are obligated to keep all information about patients confidential, which means not disclosing any patient-related information to unauthorized individuals. This includes refraining from discussing patient cases with others who are not directly involved in the care of the patient. Sharing patient information without consent can be a breach of trust and privacy, which can have legal and ethical implications. Therefore, in order to uphold the principle of confidentiality, nurses must keep all matters about the patient as a secret.

Correct Answer: C

Rationale: Scabies is a contagious skin infestation caused by the Sarcoptes scabiei mite. The classic presentation of scabies includes a rash characterized by erythematous papules and vesicles that are arranged in a linear or burrow-like distribution. These linear tracks are often seen in areas such as the interdigital spaces, wrists, elbows, axillae, belt line, and genitalia. It is commonly associated with intense itching, especially at night. Unlike psoriasis, which presents with silvery scales and well-defined borders, or contact dermatitis, which results from exposure to a specific allergen or irritant, scabies is caused by a parasitic mite infestation. Atopic dermatitis, on the other hand, is a chronic inflammatory skin condition characterized by pruritic eczematous lesions, but it typically does not manifest with a linear distribution of lesions like scabies.

Correct Answer: D

Rationale: Complete abortion is the most likely cause of the symptoms described. In a complete abortion, all products of conception are expelled from the uterus. Symptoms include vaginal bleeding, passage of tissue, and dilation of the cervix. In this scenario, the presentation of a dilated cervix with visualized products of conception is classic for a complete abortion at 10 weeks gestation.

Correct Answer: A

Rationale: The most appropriate intervention for managing hepatic encephalopathy in this patient receiving palliative care for end-stage liver disease is to administer lactulose or other ammonia-lowering agents to reduce ammonia levels. Hepatic encephalopathy is believed to be primarily caused by the accumulation of ammonia in the bloodstream due to compromised liver function. Lactulose works by acidifying the gut lumen, which facilitates the excretion of ammonia in the form of ammonium ions. By reducing ammonia levels, hepatic encephalopathy symptoms, such as confusion and altered mental status, can be improved. Initiating other supportive measures like managing precipitating factors, maintaining hydration, and addressing nutritional issues should also be part of the holistic approach in managing hepatic encephalopathy in palliative care. However, addressing the underlying cause by reducing ammonia levels with lactulose is the priority intervention in this scenario.

Correct Answer: B

Rationale: Malpractice is a type of tort that involves professional negligence or misconduct by a professional such as a nurse that results in harm to a patient. In this scenario, failing to obtain informed consent before performing a procedure is considered a breach of the standard of care expected from a healthcare professional, which falls under malpractice. This failure to obtain informed consent deprives the patient of the right to make an informed decision about their treatment and can lead to legal consequences for the nurse.

Correct Answer: C

Rationale: In pneumothorax, air enters the normally negative pressure space between the lung and chest wall, leading to loss of negative intra-pleural pressure. However, this loss of negative pressure typically does not directly result in lung collapse. Instead, the accumulation of air in the pleural space can lead to a pressure imbalance, causing the lung to collapse partially or completely, which is known as atelectasis. Therefore, it is more accurate to state that the loss of negative intra-pleural pressure can result in lung collapse due to the presence of air in the pleural space, rather than the loss of negative pressure itself causing the collapse.

Correct Answer: A

Rationale: When a patient is prescribed with an angiotensin-converting enzyme (ACE) inhibitor for managing hypertension, the nurse should monitor closely for signs of hyperkalemia. ACE inhibitors can affect the renin-angiotensin-aldosterone system, leading to decreased aldosterone secretion and impaired potassium excretion by the kidneys. As a result, potassium levels in the blood may increase, leading to hyperkalemia.