Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?

Correct Answer: D

Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.

Correct Answer: A

Rationale: The best response by the supervisor is to acknowledge the newly hired nurse's emotions by saying, "I understand how you feel. Tell me more." This response shows empathy and validates the nurse's feelings, creating a supportive environment for open communication. It allows the nurse to express their concerns and fears, leading to a constructive discussion and providing an opportunity for guidance and reassurance. This approach fosters a positive mentorship and learning experience for the newly hired nurse.

Correct Answer: D

Rationale: Antiphospholipid syndrome is characterized by abnormal antiphospholipid antibodies, which can lead to an increased risk of blood clots such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The two most common antiphospholipid antibodies are anticardiolipin and lupus anticoagulant. Patients with antiphospholipid syndrome can present with recurrent thrombotic events, such as DVT and PE, due to the pro-thrombotic effects of these antibodies. Protein C deficiency, Protein S deficiency, and Antithrombin III deficiency are other causes of hypercoagulability but would not typically present with elevated antiphospholipid antibodies.

Correct Answer: C

Rationale: The given patient with chronic kidney disease (CKD) is likely experiencing uremic bleeding diathesis. Uremic bleeding diathesis is a complication of CKD characterized by abnormal platelet function, leading to a tendency for bleeding. The presence of anemia, thrombocytopenia (low platelet count), pale skin, easy bruising, and elevated blood urea nitrogen (BUN) and creatinine levels are all consistent with uremic bleeding diathesis.

Correct Answer: D

Rationale: Fats are essential for the absorption of vitamin K in the body. Vitamin K is a fat-soluble vitamin, meaning it is better absorbed in the presence of dietary fats. In the case of postpartum hemorrhage, adequate levels of vitamin K are crucial for proper blood clotting. Thus, incorporating fats in the diet can help ensure sufficient absorption of vitamin K, which can be beneficial in preventing complications related to hemorrhage.

Correct Answer: C

Rationale: When encountering patients who are stressed due to their health condition, the best way for a nurse to communicate is through empathizing. Empathy involves understanding and sharing the feelings of another person, which can help the nurse connect with the patient on an emotional level. Empathizing allows the nurse to show genuine care and concern for the patient's well-being, fostering a trusting and supportive relationship. This approach can help alleviate the patient's stress and make them feel understood and supported during a difficult time. Sympathizing and sharing may come across as insincere or minimize the patient's experiences, while listening is important but combining it with empathy enhances the overall communication experience.

Correct Answer: D

Rationale: Clubbing of the fingers is a specific term that Nurse Gladys should write in her charting when a patient is suffering from a change in the angle between the nail base greater than 180 degrees due to congenital heart disease. Clubbing of the fingers is a diagnostic sign associated with various medical conditions, including congenital heart disease. It is characterized by changes in the angle and shape of the nails, typically involving softening of the nail bed, enlargement of the fingertips, and a loss of the normal angle between the nail and the nail bed. Peripheral neuropathy, inflammation of the fingers, and peripheral cyanosis are different conditions and do not specifically describe the nail changes seen in clubbing.

Correct Answer: D

Rationale: The best course of action in this scenario is to place a warm wet washcloth over Claudia's eyes for at least three minutes. This will help soften and loosen the dried crust, making it easier to gently clean her eyes and open them. Applying eye drops or ointment may not be effective if the crust is blocking her eyes completely. By using a warm wet washcloth, you can improve the ability to clean her eyes effectively and without causing discomfort.

Correct Answer: B

Rationale: Submitting the audiotape to their research adviser is the appropriate action for the group to take after transcription. It is important to maintain the audiotape as a research record for verification purposes, especially if any discrepancies arise during the analysis of the transcript. The research adviser can provide guidance on how to securely store or handle the audiotape in compliance with research ethics and data protection guidelines. This ensures the integrity of the research process and supports transparency in the event of any future inquiries or validation requirements. Keeping a record of the audiotape and following proper protocols for its handling is essential in conducting ethical and reliable research.