Which of the following clinical manifestations will NOT be a complaint from Sarah's condition?

Correct Answer: C

Rationale: Sarah's condition seems to be related to growth and wound healing issues, based on the provided clinical manifestations. Decrease libido is typically unrelated to conditions like edema, poor wound healing, and absence of growth in the pubic area. Therefore, it would not be a complaint stemming from Sarah's condition.

Correct Answer: B

Rationale: A priority intervention for a client with multiple myeloma is to include coughing and deep breathing exercises in the plan of care. Multiple myeloma can affect the bone marrow's ability to produce healthy blood cells, including red blood cells, which can lead to anemia. Anemia can cause fatigue and shortness of breath. By encouraging coughing and deep breathing exercises, the nurse can help improve lung function, enhance oxygenation, and prevent potential respiratory complications in the client with multiple myeloma. This intervention is crucial in promoting respiratory health and overall well-being for the client.

Correct Answer: B

Rationale: Identifying persons with sputum characterized as blood stained is important in case finding for pulmonary tuberculosis (PTB) in the community. Blood stained sputum, also known as hemoptysis, is a common symptom of TB. It occurs when there is bleeding in the respiratory tract, often as a result of damage to the lungs caused by tuberculosis infection. Therefore, the presence of blood in the sputum is a significant clinical finding that should alert healthcare providers, including nurses, to the possibility of TB. Early identification and diagnosis of individuals with blood stained sputum can lead to prompt treatment and the prevention of further transmission of the disease in the community.

Correct Answer: C

Rationale: The most appropriate action for a concerned nurse when nurses are projected as sex symbols in a television advertisement is to make a position paper to denounce the advertisement. This approach allows the nurse to voice their concerns in a formal and professional manner. By creating a position paper, the nurse can clearly outline why the portrayal is inappropriate and advocate for more respectful representations of nursing in the media. This action is constructive, proactive, and focuses on initiating change through advocacy and education. It is a thoughtful and strategic way to address the issue and raise awareness about the importance of respecting the nursing profession.

Correct Answer: B

Rationale: The IR (Incident Report) typically focuses on the details surrounding an incident or event, such as what happened, who was/were involved, and who witnessed the incident. Information about daily medications given to the patient is not usually included in an incident report, unless it directly relates to the incident itself (e.g., medication error). The primary focus of an incident report is to document the incident in a clear and factual manner for record-keeping and analysis purposes.

Correct Answer: C

Rationale: The clinical presentation of fever, malaise, maculopapular rash starting on the face and spreading to the trunk and extremities, along with leukopenia and thrombocytopenia, is highly suggestive of Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii. RMSF is a tick-borne illness transmitted by the American dog tick, Rocky Mountain wood tick, and brown dog tick. The constellation of symptoms described aligns well with the typical presentation of RMSF. Borrelia burgdorferi causes Lyme disease, which presents with erythema migrans but does not typically cause leukopenia or thrombocytopenia. Plasmodium falciparum is the causative agent of severe malaria and would present with symptoms such as cyclic fevers, anemia, and jaundice but not the described rash distribution.

Correct Answer: C

Rationale: The patient's presentation of jaundice, ascites, spider angiomas, elevated serum bilirubin levels, prolonged prothrombin time, and hypoalbuminemia are all indicative of cirrhosis. Cirrhosis is a late stage of liver disease characterized by liver scarring and poor liver function. Jaundice, which is the yellowing of the skin and eyes due to elevated bilirubin levels, is a common manifestation of liver dysfunction seen in cirrhosis. Ascites, the accumulation of fluid in the abdomen, is also a common complication of cirrhosis. Spider angiomas, which are small blood vessels near the skin's surface, are a result of altered blood flow in the liver due to cirrhosis. Prolonged prothrombin time and hypoalbuminemia are consequences of reduced liver synthesis function in cirrhosis. Hepatic encephalopathy and hepatorenal syndrome

Correct Answer: A

Rationale: Pneumothorax is a condition characterized by the presence of air in the pleural space surrounding the lungs, which can lead to lung collapse. The nurse's assessment findings in a patient with pneumothorax are typically as follows:

Correct Answer: B

Rationale: In patients with Rheumatic fever, typical manifestations include an increase in body temperature, non-pruritic rashes, and migratory joint pains. Voluntary muscle spasm is not a typical manifestation of Rheumatic fever. The main clinical features of Rheumatic fever are related to the inflammation of the heart, joints, skin, and central nervous system. Muscle spasms are not a prominent feature of this condition. It is important for the nurse to be aware of these typical manifestations to effectively monitor and manage the patient's condition.