Upon clinical assessment, the nurse observes that the OUTSTANDING manifestation of the patient is ______.

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Question 1 of 9

Upon clinical assessment, the nurse observes that the OUTSTANDING manifestation of the patient is ______.

Correct Answer: D

Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.

Question 2 of 9

A nurse is preparing to perform a urinary catheterization for a patient. What action should the nurse take to ensure proper insertion technique?

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.

Question 3 of 9

In order to determine the patient's ability to concentrate and focus, which would be the PRIORITY nursing action?

Correct Answer: C

Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.

Question 4 of 9

A pregnant woman presents with recurrent episodes of severe abdominal pain, bloating, and constipation. On examination, an abdominal mass is palpable, and bowel sounds are diminished. Which of the following conditions is the most likely cause of these symptoms?

Correct Answer: D

Rationale: Ovarian torsion is the most likely cause of the pregnant woman's symptoms as described. Ovarian torsion occurs when the ovary twists on its pedicle, leading to compromised blood flow to the ovary. This can cause severe abdominal pain, bloating, and constipation. On examination, an abdominal mass may be palpable due to an enlarged, twisted ovary. Bowel sounds may be diminished due to the effect of the torsion on surrounding structures. Ectopic pregnancy, threatened abortion, and placenta previa are less likely to present with an abdominal mass and diminished bowel sounds.

Question 5 of 9

A patient presents with acute onset of severe vertigo, nausea, vomiting, and nystagmus. Symptoms are worsened with head movement. Which of the following neurological conditions is most likely responsible for these symptoms?

Correct Answer: B

Rationale: Vestibular neuritis is a condition characterized by the acute onset of severe vertigo, nausea, vomiting, and nystagmus. These symptoms are typically worsened by head movement. Vestibular neuritis is caused by inflammation of the vestibular nerve, which plays a key role in balance and spatial orientation. The classic presentation of these symptoms, along with the absence of hearing loss (which is seen in labyrinthitis), points towards vestibular neuritis as the most likely cause in this scenario. Meniere's disease presents with recurrent episodes of vertigo, hearing loss, tinnitus, and sensation of fullness in the ear. Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo triggered by changes in head position.

Question 6 of 9

Nurse Lyca is aware that testing of vision in infants and children has been treated separately from the testing of adult. which of the statement is NOT true?

Correct Answer: E

Rationale: All of the statements (A-D) are true when discussing the testing of vision in infants and children separately from testing in adults. However, statement E is NOT true. The course of visual and cognitive development MUST be taken into account in evaluating infants and children's visual abilities. It is crucial to consider the stage of development a child is in when evaluating their vision, as their visual abilities can change rapidly during early childhood. Ignoring the course of development could lead to incorrect assessments and misunderstandings about the child's visual capabilities.

Question 7 of 9

A patient presents with a thyroid nodule and signs of compression such as difficulty swallowing and breathing. Fine-needle aspiration biopsy reveals a follicular pattern and colloid-filled spaces. Which endocrine disorder is most likely responsible for these symptoms?

Correct Answer: C

Rationale: The patient's presentation of thyroid nodule with compression symptoms like difficulty swallowing and breathing, along with fine-needle aspiration biopsy showing a follicular pattern and colloid-filled spaces, is highly suggestive of a follicular adenoma. Follicular adenomas are benign thyroid tumors that can cause compression symptoms due to their growth and size, leading to pressure on surrounding structures in the neck area. The presence of colloid-filled spaces in the biopsy is characteristic of follicular adenomas.

Question 8 of 9

A postpartum client presents with persistent, severe abdominal pain, tenderness, and rigidity. Which nursing action is most appropriate?

Correct Answer: C

Rationale: Persistent, severe abdominal pain, tenderness, and rigidity in a postpartum client can be indicative of serious conditions such as uterine rupture, hemorrhage, or infection, which require urgent medical attention. As a nurse, the priority action in this situation is to notify the healthcare provider immediately so that appropriate interventions can be initiated promptly to ensure the safety and well-being of the client. Administering analgesics or providing emotional support may not address the underlying cause of the symptoms and could potentially delay necessary medical treatment. Assisting the client to a comfortable position can be considered once the healthcare provider has been informed and appropriate assessments and interventions have been initiated.

Question 9 of 9

Transcription of doctor's order is a nurse's responsibility to put the order into action. Which of the following principles of medication safety is NOT considered to belong to transcription error?

Correct Answer: D

Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.

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