Which of the following interventions is appropriate for managing a conscious patient with a severe nosebleed (epistaxis)?

Correct Answer: B

Rationale: When managing a conscious patient with a severe nosebleed (epistaxis), the appropriate intervention is to have the patient sit upright and lean slightly forward to prevent blood from flowing into the throat and causing choking or swallowing. Pinching the soft part of the nose just below the bony part can help apply pressure to the bleeding vessel and stop the bleeding. This maneuver also helps compress the blood vessels in the nose, promoting clot formation and stopping the bleeding. It is important not to tilt the head back as this can cause blood to flow into the throat and potentially lead to swallowing, choking, or aspiration. Packing the nose with cotton gauze should be done by medical professionals if the bleeding does not stop with direct pressure. Applying direct pressure to the forehead is not effective for managing nosebleeds; pressure should be applied to the nostrils instead.

Correct Answer: C

Rationale: Mastitis is an infection of the breast tissue that may occur in postpartum clients. When a postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth, it is crucial to notify the healthcare provider immediately. Prompt medical evaluation is necessary to determine the appropriate treatment plan, which may include antibiotics. Delay in treatment can lead to complications, such as abscess formation. Encouraging the client to continue breastfeeding and applying warm compresses may provide some relief but do not address the underlying infection. Administering oral antibiotics would require a prescription from the healthcare provider, hence notifying the provider is the most appropriate initial nursing action in this situation.

Correct Answer: C

Rationale: A dental abscess is characterized by a localized collection of pus that results from a bacterial infection of the tooth pulp, leading to swelling, pain, and inflammation. The infection typically occurs when bacteria enter the tooth through a cavity, crack, or other dental injury. The abscess can cause significant pain and discomfort and must be treated promptly by a dentist to prevent further complications. Dental caries refer to tooth decay or cavities that result from the breakdown of tooth structure by acids produced by bacteria. Periodontitis is a severe gum infection that damages the soft tissue and destroys the bone that supports the teeth. Oral candidiasis is a fungal infection that affects the mouth and throat.

Correct Answer: B

Rationale: The priority nursing diagnosis for a patient undergoing surgery (closure of the sac) would be risk for infection. This is because surgical procedures increase the risk of infection due to the breach in the skin and introduction of microorganisms. Infection can lead to serious complications, delay healing, and prolong recovery time. Therefore, prevention, early detection, and prompt treatment of infections are essential in the perioperative period to ensure the best possible outcomes for the patient.

Correct Answer: B

Rationale: Performing a sigmoidoscopy, which is a procedure to examine the lower part of the colon and rectum, during a health screening event at a community center may not be practical for several reasons. Firstly, sigmoidoscopy is relatively invasive compared to other screening methods for colon cancer, such as fecal occult blood tests or colonoscopy. Secondly, it can be expensive to perform, especially in a community setting where cost-effectiveness is an important consideration. Therefore, Nurse Filomena would likely point out the invasiveness and cost factors to explain why a sigmoidoscopy may not be suitable for a health screening event at a local community center.

Correct Answer: C

Rationale: The nurse's primary responsibility in responding to a patient's questions about their diagnosis and treatment options is to listen actively and provide accurate, honest, and comprehensive answers. This approach helps build trust between the patient and the healthcare team, allows the patient to make informed decisions about their care, and ensures that the patient understands their condition and the recommended treatment plan. Providing vague answers or ignoring the patient's questions can lead to confusion, anxiety, and mistrust, which can hinder the patient's overall care and recovery. Referring the patient to the physician for all questions may be appropriate for certain medical inquiries, but the nurse plays a crucial role in educating and supporting the patient throughout their healthcare journey.

Correct Answer: C

Rationale: Neuman's adaptation model, also known as the Neuman Systems Model, is a nursing theory that focuses on how individuals respond to stressors in their environment. The model views individuals as being in a constant state of dynamic equilibrium, where they are interacting with stressors that can disrupt their normal functioning. Nursing care, according to this model, is aimed at helping individuals maintain or restore their optimal level of wellness by assisting them in adapting to these stressors. Therefore, Nurse Sandy's selection of a framework that emphasizes the constant relationship between humans and stressors in the environment aligns best with Neuman's adaptation model.

Correct Answer: D

Rationale: Complete abortion is the most likely cause of the symptoms described. In a complete abortion, all products of conception are expelled from the uterus. Symptoms include vaginal bleeding, passage of tissue, and dilation of the cervix. In this scenario, the presentation of a dilated cervix with visualized products of conception is classic for a complete abortion at 10 weeks gestation.

Correct Answer: B

Rationale: Cultural competence is the process of acquiring specific knowledge, skills, and attitudes to effectively work with individuals from diverse cultural backgrounds. It involves understanding and respecting the values, beliefs, languages, and practices of different cultures in order to provide appropriate care and services. Cultural competence goes beyond just learning about different cultures; it requires the development of skills and attitudes that promote effective communication, understanding, and collaboration with individuals of diverse backgrounds. This includes being aware of one's own biases, being open-minded, and adapting practices to be inclusive and respectful of cultural differences. Ultimately, cultural competence is essential in providing high-quality, respectful, and effective care to clients from various cultural backgrounds.