Which of the following conditions does the nurse explain to the patient the contributory factor that slows uterine involution?

Correct Answer: C

Rationale: Prolonged labor is a condition in which labor lasts for an extended period, typically more than 20 hours for first-time mothers and more than 14 hours for experienced mothers. Prolonged labor can contribute to slowing down uterine involution because the prolonged pressure and strain on the uterus can affect its ability to return to its pre-pregnancy size and position. The prolonged contractions and stretching of the uterine muscles can hinder the normal process of uterine involution, leading to a delay in the uterus shrinking back to its non-pregnant state. Additionally, prolonged labor can increase the risk of postpartum complications such as excessive bleeding and infection, which can further impact uterine involution. Therefore, it is crucial for healthcare providers to monitor labor progress closely to prevent prolonged labor and its potential effects on uterine involution.

Correct Answer: A

Rationale: The nurse should prioritize adjusting the irrigation flow rate based on the patient's urine output to prevent complications during continuous bladder irrigation (CBI). Proper adjustment of the irrigation flow rate helps maintain adequate bladder drainage while preventing bladder distention, clot formation, and potential irrigation fluid overload. Monitoring the patient's urine output and adjusting the flow rate accordingly ensures optimal functioning of the CBI system and enhances patient safety. This proactive approach minimizes the risk of complications and promotes effective postoperative care following urological surgery.

Correct Answer: B

Rationale: Metformin is a commonly prescribed medication for the treatment of type 2 diabetes mellitus. One of the rare but serious adverse effects associated with metformin use is lactic acidosis. Lactic acidosis results from the buildup of lactic acid in the bloodstream, leading to symptoms such as weakness, rapid breathing, abdominal pain, and muscle pain. Lactic acidosis can be life-threatening and requires immediate medical attention. It is important for patients taking metformin to be aware of the signs and symptoms of lactic acidosis and seek immediate medical help if they experience any of these symptoms. Regular monitoring of kidney function is crucial in patients taking metformin to reduce the risk of lactic acidosis.

Correct Answer: A

Rationale: The most appropriate intervention for managing hepatic encephalopathy in this patient receiving palliative care for end-stage liver disease is to administer lactulose or other ammonia-lowering agents to reduce ammonia levels. Hepatic encephalopathy is believed to be primarily caused by the accumulation of ammonia in the bloodstream due to compromised liver function. Lactulose works by acidifying the gut lumen, which facilitates the excretion of ammonia in the form of ammonium ions. By reducing ammonia levels, hepatic encephalopathy symptoms, such as confusion and altered mental status, can be improved. Initiating other supportive measures like managing precipitating factors, maintaining hydration, and addressing nutritional issues should also be part of the holistic approach in managing hepatic encephalopathy in palliative care. However, addressing the underlying cause by reducing ammonia levels with lactulose is the priority intervention in this scenario.

Correct Answer: A

Rationale: Crisis intervention is an important part of secondary prevention in the care of families. Secondary prevention involves activities that aim to reduce the impact of a crisis or event that has already occurred. Crisis intervention provides immediate support and strategies to help families cope with and overcome a crisis situation. By addressing the crisis quickly and effectively, secondary prevention can help prevent further negative outcomes and promote the well-being of the family members.

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: A

Rationale: Difficulty of speaking and chewing is an indicator of cranial nerve involvement. Cranial nerves are responsible for controlling various functions of the head and neck, including speech and mastication. Impairment of cranial nerve function can lead to difficulty in these activities. In the context of the question, with the patient in the stroke unit, cranial nerve involvement can occur due to the stroke affecting the brain regions responsible for cranial nerve function. Loss of pain sensation, spastic paralysis of the extremities, and forgetfulness with syncope are not specific indicators of cranial nerve involvement in this scenario.

Correct Answer: B

Rationale: The PRIMARY goal of CO-PAR (Community-based Participatory Action Research) is to make the community empowered and self-reliant. CO-PAR emphasizes collaboration between researchers and the community members to address issues that directly affect the community. This approach prioritizes community empowerment, leading to sustainable solutions and positive changes within the community. The goal is not just about enhancing individual skills, increasing funding, or beautifying the community, but rather about fostering community ownership and self-reliance in problem-solving and decision-making processes.

Correct Answer: C

Rationale: Severe nausea and vomiting with a large volume of vomitus can indicate a serious underlying issue such as gastrointestinal obstruction or other medical emergencies. In this situation, it is crucial for the nurse to notify the physician immediately so that further assessment and appropriate management can be initiated promptly. Delay in seeking medical help can lead to complications and worsen the patient's condition. It is important to act quickly and involve the physician in situations where the patient's health may be at risk.