The patient seems indecisive whether to breastfeed her baby or not. Which is the desired nursing action of Nurse Vera to help the pregnant patient make a decision on breastfeeding?

Correct Answer: D

Rationale: The desired nursing action to help the pregnant patient make a decision on breastfeeding is to assist in identifying a breastfeeding goal and plan. When patients are indecisive about breastfeeding, it is essential for the nurse to support them in setting specific goals and creating a plan that aligns with their values and circumstances. This approach can help the patient feel empowered and confident in their decision-making process. Providing pamphlets and books (choice A) may be helpful, but personalized assistance in identifying a breastfeeding goal and plan is more likely to address the patient's individual needs and concerns. Providing ample time for the patient to decide (choice B) is important, but guidance and support in setting a clear goal can facilitate the decision-making process. Referring the patient to a nutritionist (choice C) may be beneficial for dietary concerns but may not directly address the decision-making process regarding breastfeeding.

Correct Answer: C

Rationale: The most appropriate nursing action for managing a patient with dependent edema in the lower extremities is to administer diuretics as prescribed. Diuretics help the body remove excess fluid, reducing swelling and edema in the extremities. It is important to follow the healthcare provider's orders for administering diuretics to ensure the patient's fluid balance is managed effectively. While elevating the legs above heart level and applying compression stockings may provide temporary relief, addressing the underlying cause of fluid retention with diuretics is essential for long-term management of the edema in a patient with heart failure. Encouraging increased fluid intake would not be appropriate in this case, as the focus should be on reducing fluid overload rather than increasing fluid intake.

Correct Answer: A

Rationale: At the concrete operational stage according to Piaget's theory, children typically demonstrate logical thinking abilities and are able to understand and work with concrete objects and events. They can also grasp concepts such as conservation and classification. These children are able to think logically about concrete events but may still struggle with abstract and hypothetical situations. Therefore, Belle, functioning at the concrete operational stage, would exhibit behaviors such as thinking logically and being able to see possibilities, as described in option A.

Correct Answer: B

Rationale: Urinary incontinence is a common complication associated with prostatectomy for the treatment of benign prostatic hyperplasia (BPH). Prostate surgery, such as a prostatectomy, can disrupt the sphincter muscle that controls the flow of urine from the bladder, leading to temporary or even long-term urinary incontinence in some patients. This usually improves over time with pelvic floor exercises and other treatment options, but it is an important consideration when discussing the potential risks and benefits of prostate surgery with patients. While erectile dysfunction and retrograde ejaculation can also be potential side effects of prostate surgery, urinary incontinence is specifically associated with issues related to bladder control following the procedure. Urethral stricture, although it can occur post prostate surgery, is less common compared to urinary incontinence.

Correct Answer: C

Rationale: In this situation, the most appropriate response for the palliative nurse is to validate the patient's feelings of guilt and offer support to address their concerns. It is important to acknowledge the patient's emotions and help them navigate through their guilt in a compassionate and understanding manner. By validating their feelings, the nurse can create a safe space for the patient to express their concerns and work towards finding solutions to alleviate their guilt. This approach fosters trust and a therapeutic relationship between the patient and the nurse, ultimately promoting emotional well-being and facilitating open communication.

Correct Answer: A

Rationale: The presentation described, involving multiple grouped vesicles on an erythematous base in the genital area, is classic for herpes simplex genitalis. This condition is caused by the herpes simplex virus (HSV) and is characterized by recurrent outbreaks of painful vesicles in the genital or perianal area. The history of similar lesions occurring during periods of stress is also suggestive of herpes simplex virus reactivation. Genital warts (condyloma acuminata) typically present as painless, fleshy growths in the genital area caused by human papillomavirus (HPV). Syphilis manifests as a painless ulcer known as a chancre, which is not described in the presentation. Molluscum contagiosum presents with pearly, dome-shaped papules with central umbilication, rather than vesicles.

Correct Answer: A

Rationale: To help the students better understand the anatomy of the breast, it is crucial to provide visual aids that display both external and internal views of the breast. By sharing various pictures of the breast, students can visually learn about the structure, shape, location of different components, such as lobes, ducts, glands, and lymph nodes. Visual aids enhance the learning experience by providing a clear representation of the complex anatomical features of the breast, aiding in retention and comprehension. This approach can effectively supplement theoretical knowledge with practical visual references, facilitating a comprehensive understanding of breast anatomy.

Correct Answer: B

Rationale: Mastitis is typically caused by bacterial infection, with predisposing factors including milk stasis (I) and nipple trauma (II). Milk stasis occurs when milk is not effectively removed from the breast, leading to a build-up that can block ducts and predispose to infection. Nipple trauma, such as cracks or damage, can provide entry points for bacteria to infect the breast tissue. Factors like using alcohol in cleaning nipples (III) and the baby's sitting position (IV) are not directly associated with the development of mastitis.

Correct Answer: B

Rationale: Cell-mediated immunity is a type of immune response that involves the activation of cytotoxic T cells and other immune cells to directly target and destroy infected or abnormal cells. It does not involve the production of antibodies, which are the primary component of humoral immunity. Antibodies are produced by B cells and are responsible for targeting extracellular pathogens such as bacteria and viruses. In contrast, cell-mediated immunity is more focused on targeting intracellular pathogens, cancerous cells, and other cells that have been compromised. So, production of antibodies is not usually associated with cell-mediated immunity.