Upon further assessment, you notices that she had any scratches on her right ankle, a resulting infection, and cellulitis. When you asked her about the scratches, the patient states, "Oh, my cat might have been using my leg as a scratiching post again and I did not even feel it." Which diabetic complicatons suspect the patient to have?

Correct Answer: A

Rationale: The patient's lack of sensation in her right leg, allowing her cat to scratch her without her noticing, is indicative of neuropathy. Neuropathy is a common diabetic complication characterized by nerve damage that can result in loss of sensation or altered sensation in different parts of the body, including the extremities. In this case, neuropathy has likely affected the patient's right lower extremity, leading to her inability to feel the cat scratching her leg and resulting in the unnoticed scratches, infection, and subsequent cellulitis.

Correct Answer: B

Rationale: Radiologic procedures are typically not used as the least screening assessment by nurses in a perinatal unit. The nurse's initial screening assessments usually focus on gathering information through techniques such as physical examination, interviews, and reviewing laboratory results. Radiologic procedures, such as X-rays or CT scans, are usually ordered by physicians once a more specific diagnostic need has been identified, based on the initial screening assessments performed by the nurse. Therefore, in this scenario, the least screening assessment to be used by the nurse would be radiologic procedures.

Correct Answer: D

Rationale: Fidelity is a principle of ethics that relates to being faithful or loyal to one's commitments and responsibilities. When Nurse Pat promises to assist the post-surgical patient with ambulation after carrying out the physician's order, she is demonstrating fidelity by honoring her commitment to the patient. This principle highlights the importance of keeping promises, being reliable, and maintaining trust in the nurse-patient relationship.

Correct Answer: A

Rationale: In a patient with acute gastrointestinal bleeding requiring urgent intervention, the healthcare team should prioritize performing endoscopic hemostasis with mechanical or thermal techniques. Endoscopy allows for direct visualization of the source of bleeding in the gastrointestinal tract, enabling targeted interventions such as clipping, cauterization, or injection of epinephrine to achieve hemostasis. This approach is effective in managing acute bleeds and can help stop the bleeding quickly, reducing the need for more invasive procedures or surgeries. Administering proton pump inhibitors (PPIs) may be considered for acid-related bleeding, but it is not the primary intervention for acute bleeding requiring urgent management. Strict bed rest may not be necessary and can increase the risk of complications such as deep vein thrombosis. Transfusion of fresh frozen plasma may be indicated if there is evidence of coagulopathy, but addressing the bleeding source should be the initial priority to

Correct Answer: C

Rationale: Feces, urine, blood, and other body fluids are considered as vehicles of transmission in the context of communicable diseases. These substances can carry and transmit disease-causing microorganisms such as bacteria, viruses, and parasites from infected individuals to others. Through close contact or exposure to these contaminated body fluids, the pathogens can enter the body of another person and cause infection. Nurses like Nurse Keena must exercise caution and use appropriate infection control measures to prevent transmission of communicable diseases through these vehicles.

Correct Answer: A

Rationale: A nursing assistant can be delegated the task of changing wound dressings because it is considered a basic nursing care activity that does not require specialized training or knowledge. Nursing assistants are trained to perform tasks related to personal care, hygiene, and basic wound care under the supervision of a registered nurse. Changing wound dressings is a routine nursing task that can be safely delegated to a nursing assistant, allowing the nurse to focus on other aspects of patient care that require specialized nursing skills and knowledge.

Correct Answer: A

Rationale: Selective IgA deficiency is a primary immunodeficiency disorder characterized by low or absent levels of immunoglobulin A (IgA) in the blood. Since IgA plays a crucial role in mucosal immunity and defense against pathogens at mucosal surfaces, individuals with this deficiency are more susceptible to recurrent bacterial infections, particularly of the respiratory and gastrointestinal tracts. In contrast, severe combined immunodeficiency (SCID) is a more severe immunodeficiency disorder affecting T and B lymphocytes, chronic granulomatous disease (CGD) is a disorder of phagocytes, and autoimmune hemolytic anemia is an autoimmune disease involving red blood cells, none of which are directly associated with selective IgA deficiency.

Correct Answer: A

Rationale: The response indicating Annie's present condition would be option A. This is because the symptoms mentioned in option A, such as experiencing vertigo, nausea, and nystagmus when sitting, point towards a vestibular disorder. These are symptoms commonly associated with conditions like Meniere's disease or vestibular neuritis, which can cause balance issues and feelings of dizziness. These symptoms are more indicative of Annie's current health status compared to the other options which focus on past or unrelated issues, such as ear pain during travel or impaired hearing since birth. The information provided in option A gives a more direct insight into Annie's present condition, making it the most appropriate response.

Correct Answer: B

Rationale: Nitrous oxide, also known as "laughing gas," is a safe and effective pharmacological option for pain management during labor. Nitrous oxide is commonly used in labor and delivery settings as it has minimal effects on the baby and allows the woman to remain in control of her pain management. It provides quick pain relief when inhaled and can be adjusted to the woman's needs during labor. Ibuprofen, morphine, and diazepam are not typically used for pain management during labor due to their potential risks and side effects, especially for the baby.