Which intervention should the nurse use to promote rest?

Correct Answer: A

Rationale: Developing a routine with the patient to balance her studies and rest needs is the most appropriate intervention to promote rest. This approach considers the patient's responsibilities and can help her organize her time effectively to ensure she gets adequate rest while managing her studies. It acknowledges the importance of rest without completely disregarding the patient's other commitments, ultimately fostering a balanced approach to self-care. This intervention is patient-centered and collaborative, empowering the patient to take an active role in prioritizing rest alongside her educational responsibilities.

Correct Answer: B

Rationale: The patient's presentation with sudden-onset severe lower abdominal pain, nausea, vomiting, inability to pass urine, suprapubic tenderness, and a palpable bladder is classic for acute urinary retention. Acute urinary retention is a urological emergency characterized by the sudden inability to pass urine due to the inability to empty the bladder completely. The palpable bladder on physical examination indicates significant bladder distension. This condition can be caused by multiple factors such as bladder outlet obstruction, neurogenic causes, or medications affecting bladder function. Prompt intervention is necessary to relieve the bladder distension, alleviate symptoms, and prevent complications like bladder rupture.

Correct Answer: B

Rationale: The presentation described is consistent with nummular eczema, also known as discoid eczema. Nummular eczema typically presents as circular or oval-shaped patches of eczematous rash with fine scaling and central clearing. It is often pruritic and can be triggered by exposure to irritants such as new soaps or laundry detergents. The distribution on the trunk and proximal extremities is also typical for nummular eczema. Tinea corporis (ringworm) would present with a more raised, scaly, and well-defined border with central clearing. Pityriasis rosea presents with a herald patch followed by smaller oval or round lesions in a "Christmas tree" distribution. Lichen planus would present with polygonal, purplish, flat-topped papules typically located on flexural surfaces and extremities.

Correct Answer: C

Rationale: The nurse should always keep Tensilon (Edrophonium) at the bedside of a client with myasthenia gravis. Tensilon is a fast-acting cholinesterase inhibitor that can be used for the diagnosis and emergency treatment of myasthenia crisis. It helps improve muscle strength temporarily by increasing the levels of acetylcholine at the neuromuscular junction. Administering Tensilon can help differentiate between a myasthenic crisis (marked improvement in muscle strength) and a cholinergic crisis (no improvement or worsening of muscle weakness). Keeping Tensilon at the bedside allows for prompt administration in case of a myasthenic crisis.

Correct Answer: A

Rationale: Maternal dehydration can contribute to a prolonged latent phase during labor. Dehydration can lead to reduced blood volume and electrolyte imbalances, which can result in ineffective uterine contractions. Without adequate hydration, the uterus may not contract effectively, causing irregular and infrequent contractions. It is important for the nurse to assess the woman's hydration status and encourage her to stay hydrated during labor to help regulate contractions and progress labor.

Correct Answer: B

Rationale: In a professional setting like a classroom or a meeting, it is important for the CI (chief instructor) to set the atmosphere by welcoming everyone and discussing the objectives of the ward class. By discussing the objectives, the CI can provide a clear direction for the session and ensure that everyone is on the same page in terms of what needs to be accomplished. This not only helps focus the participants but also creates a sense of purpose and organization, setting a positive tone for the rest of the interaction. Showing a picture of the breast or giving an anecdote about an old man may not be appropriate or relevant in this context. Going ahead with the first part of the lecture without any welcoming or setting the atmosphere may make the participants feel rushed or disconnected from the session's purpose.

Correct Answer: D

Rationale: A family history of breast cancer is a known risk factor for the development of ovarian cancer. Individuals with a close relative (such as a mother, sister, or daughter) who has had breast cancer have a higher risk of developing ovarian cancer. This increased risk is due to shared genetic factors that can predispose individuals to both breast and ovarian cancers. Therefore, having a family history of breast cancer is an important risk factor to consider in the assessment of ovarian cancer risk.

Correct Answer: A

Rationale: Thrombotic thrombocytopenic purpura (TTP) is a rare but serious condition characterized by microangiopathic hemolytic anemia, thrombocytopenia, neurological abnormalities, fever, and renal dysfunction. The classic pentad of symptoms includes fever, neurologic changes, renal impairment, thrombocytopenia, and microangiopathic hemolytic anemia. The presence of petechiae, purpura, and mucosal bleeding along with thrombocytopenia, elevated serum creatinine, and schistocytes on peripheral blood smear are consistent with TTP. In TTP, there is usually a deficiency of ADAMTS13 (a von Willebrand factor-cleaving protease) leading to excessive platelet adhesion, aggregation, and microthrombi formation within small blood vessels. Treatment typically

Correct Answer: B

Rationale: Educating the client about the "baby blues" phenomenon should be prioritized as it is a common occurrence that happens to many women after giving birth. The "baby blues" refer to feelings of sadness, irritability, and tearfulness that many new mothers experience due to hormonal changes and the stress of adjusting to motherhood. By understanding that these feelings are a normal part of the postpartum period and that they usually resolve on their own within a few weeks, the client may feel reassured and supported. Providing information and support can help the client cope with these emotions and reduce any anxiety or distress they may be feeling. If the client's emotional state does not improve or becomes more severe, further intervention such as referring to a mental health professional may be necessary. But initially, education and reassurance about the "baby blues" can be an effective nursing intervention to address the client's emotional well-being.