Upon interview, the patient reported the she often felt nauseated, restless, perspired a lot, felt fatigued, and was often hungry when she was younger. What do these signs indicate?

Correct Answer: B

Rationale: The signs reported by the patient, such as feeling nauseated, restless, sweating excessively, fatigue, and increased hunger, are indicative of hypoglycemia, which is characterized by low blood sugar levels. In individuals with hypoglycemia, these symptoms can occur when the blood glucose levels drop too low, leading to disturbances in the body's energy supply. This is common in individuals who may have experienced episodes of low blood sugar, especially if they have a history of diabetes or are taking medications that lower blood sugar levels. Diabetic nephropathy, hyperglycemia, and diabetic retinopathy are conditions associated with high blood sugar levels and are not consistent with the symptoms described by the patient.

Correct Answer: A

Rationale: Providing emotional support and empathy for the client's experience should be prioritized to address concerns of a postpartum client who experienced a traumatic birth. Emotional support can help the client feel validated and heard, which can be instrumental in starting the healing process. By acknowledging the client's emotions and experiences, the nurse can establish trust and create a safe space for the client to express their feelings. This can also help in building a therapeutic relationship that can positively impact the client's emotional well-being. Providing a supportive environment is essential for addressing breastfeeding difficulties and emotional distress in this situation.

Correct Answer: D

Rationale: The aim of pelvic muscle exercises for a patient with urinary incontinence is to strengthen the muscles that control the vagina and urethra. These exercises, known as Kegel exercises, target the pelvic floor muscles that support the pelvic organs and help in controlling urinary function. Strengthening these muscles can help improve bladder control and reduce or eliminate urinary incontinence. Exercises that target the perineal area can also be beneficial in managing urinary incontinence, but the main focus is on strengthening the muscles that control the vagina and urethra.

Correct Answer: B

Rationale: Opsonization is a process in the immune response where opsonins, which are proteins such as antibodies and complement proteins, bind to pathogens such as bacteria, making them more easily recognized and engulfed by phagocytic cells like macrophages and neutrophils. This coating of pathogens by opsonins enhances the efficiency of phagocytosis, helping in the elimination of pathogens from the body. Opsonins do not facilitate cell lysis, neutralize toxins, or stimulate histamine release; their main function is to tag pathogens for phagocytosis.

Correct Answer: B

Rationale: The laboratory test used to monitor the therapeutic effect of warfarin therapy is the International Normalized Ratio (INR). Warfarin is a commonly prescribed anticoagulant medication that works by inhibiting the action of vitamin K-dependent clotting factors. Maintaining the INR within the target range specific to the indication for anticoagulation (e.g., DVT prevention or treatment) is essential to balance the risk of bleeding and clotting.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.

Correct Answer: D

Rationale: Ella's feeling of joining Lory in heaven is best categorized as suicidal ideation. Suicidal ideation refers to thoughts or fantasies about dying, including thoughts of one's own death or thoughts of wanting to harm oneself. In this scenario, Ella is not explicitly expressing any immediate intent to harm herself or others, nor is she exhibiting paranoia or making a direct threat. Instead, her mention of joining Lory in heaven suggests that she is contemplating the idea of death, which falls under the category of suicidal ideation. It is essential to take such thoughts seriously and seek appropriate help and support for the individual experiencing them.

Correct Answer: B

Rationale: Periodontitis is the dental condition characterized by inflammation of the gingival tissues surrounding the teeth. It is typically caused by poor oral hygiene practices, leading to plaque buildup and eventually gum disease. If left untreated, periodontitis can cause serious damage to the gum tissue and the underlying bones supporting the teeth, which can eventually result in tooth loss. Regular dental check-ups, proper oral hygiene habits, and professional cleanings are important for preventing and managing periodontitis.

Correct Answer: C

Rationale: The sudden onset of shortness of breath, chest pain, and cyanosis in a postpartum client could be indicative of a pulmonary embolism, a potentially life-threatening condition. Therefore, it is crucial to notify the healthcare provider immediately for further assessment and management. Prompt intervention is essential in this situation to prevent any potential complications and ensure the client receives appropriate care as soon as possible. Placing the client in a semi-Fowler's position or administering supplemental oxygen therapy may provide temporary relief, but the priority is to seek immediate medical attention. Consulting with the healthcare provider ensures that the client receives the necessary interventions promptly.