While patient Sarah is confined in the hospital, the safety measure to be observed by the nurses is prevention from fall. This is brought about by the patient being prone to fracture as a result of________.

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Question 1 of 9

While patient Sarah is confined in the hospital, the safety measure to be observed by the nurses is prevention from fall. This is brought about by the patient being prone to fracture as a result of________.

Correct Answer: B

Rationale: The correct answer is B: osteoporosis. Osteoporosis is a condition characterized by weakened bones, making individuals more susceptible to fractures, especially with minor trauma or falls. In the context of a patient prone to fractures, nurses should be particularly cautious about fall prevention. A: The aging process alone does not necessarily lead to an increased risk of fractures. While aging is a risk factor for osteoporosis, it is not the direct cause of fractures in this case. C: Changes in vision can contribute to an increased risk of falls, but it is not the primary reason for the patient being prone to fractures in this scenario. D: Hematologic conditions may affect bone health, but they are not typically the primary cause of increased fracture risk in patients.

Question 2 of 9

Which of the following actions should be taken first when encountering a person experiencing an allergic reaction with signs of respiratory distress?

Correct Answer: D

Rationale: The correct answer is D: Assess the severity of the reaction. This should be the first action taken because it helps determine the urgency of the situation and guides subsequent steps. Assessing the severity allows for appropriate intervention - from calling emergency services if the reaction is severe, to administering medication if necessary. A: Administering an epinephrine auto-injector should only be done if the severity of the reaction warrants it, as it is a potent medication that can have serious side effects if used inappropriately. B: Positioning the person comfortably is important, but assessing the severity of the reaction takes precedence to ensure prompt and appropriate care. C: Monitoring vital signs is important, but assessing the severity of the reaction is crucial in determining the immediate course of action.

Question 3 of 9

Annie states,'I 'm afraid to 1et my children out of my sight now that I can't hear them." What is the nurse ' s BEST response?

Correct Answer: A

Rationale: Rationale: A is the correct answer as it demonstrates therapeutic communication by encouraging Annie to express her feelings and fears. It shows empathy and understanding, allowing Annie to elaborate on her concerns. B is incorrect as it dismisses Annie's fears and implies blame on her parenting. C is incorrect as it focuses on the behavior of the children rather than addressing Annie's emotions. D is incorrect as it places the responsibility on the children to make Annie feel comfortable, rather than addressing her concerns directly.

Question 4 of 9

In as much as Almira complained of vaginal spotting and abdominal cramps, which among the following will the nurse anticipate as the MOST likely diagnosis of the physician after a vaginal examination?

Correct Answer: B

Rationale: The correct answer is B: Threatened abortion. Vaginal spotting and abdominal cramps are common symptoms of a threatened abortion, which occurs when there is a risk of miscarriage but the pregnancy remains viable. This diagnosis is likely after a vaginal examination to assess the cervix and presence of fetal heartbeat. A: Eclampsia is characterized by seizures in pregnancy due to high blood pressure, not typically presenting with vaginal spotting and cramps. C: Placenta previa involves the placenta covering the cervix, leading to painless vaginal bleeding, not associated with cramps. D: Abruptio placenta is premature separation of the placenta from the uterus, manifesting as painful bleeding, not typically with vaginal spotting and cramps.

Question 5 of 9

A patient presents with chronic nasal congestion, hyposmia, and anosmia. Nasal endoscopy reveals polypoid masses obstructing the nasal cavity and sinuses. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: C

Rationale: The correct answer is C: Nasal polyps. Nasal polyps are benign growths that form in the nasal cavity and sinuses, leading to symptoms such as chronic nasal congestion, hyposmia, and anosmia. The presence of polypoid masses seen on nasal endoscopy is characteristic of nasal polyps. Rationale: 1. Chronic nasal congestion, hyposmia, and anosmia are common symptoms of nasal polyps. 2. Nasal endoscopy revealing polypoid masses confirms the presence of nasal polyps. 3. Allergic rhinitis may cause nasal congestion but does not typically present with polypoid masses. 4. Chronic sinusitis can cause nasal congestion but is usually associated with inflammation of the sinuses, not just polypoid masses. 5. A deviated nasal septum can lead to nasal congestion but does not typically cause polypoid masses obstructing the nasal cavity and sinuses.

Question 6 of 9

A patient with a history of chronic liver disease presents with ecchymoses, mucosal bleeding, and altered mental status. Laboratory tests reveal prolonged PT and aPTT, low fibrinogen levels, and elevated D-dimer. Which of the following conditions is most likely to cause these findings?

Correct Answer: B

Rationale: The correct answer is B: Disseminated intravascular coagulation (DIC). In DIC, there is widespread activation of coagulation leading to consumption of clotting factors, resulting in prolonged PT and aPTT, low fibrinogen levels, and elevated D-dimer. This pattern matches the laboratory findings in the patient. In liver cirrhosis (choice A), there is a decrease in clotting factors synthesis, leading to prolonged PT but not aPTT. Hemophilia A (choice C) is a genetic disorder that affects specific clotting factors, typically leading to prolonged aPTT but not PT. Vitamin K deficiency (choice D) impairs the synthesis of clotting factors, leading to prolonged PT but not aPTT and low levels of factors II, VII, IX, and X.

Question 7 of 9

A patient with a history of multiple myeloma demonstrates hypogammaglobulinemia. Which of the following immunoglobulin classes is most likely to be deficient in this patient?

Correct Answer: B

Rationale: The correct answer is B: IgA. In multiple myeloma, there is a proliferation of abnormal plasma cells, leading to a decrease in normal antibody production. IgA is the most abundant immunoglobulin in mucosal secretions and plays a crucial role in mucosal immunity. Therefore, a deficiency in IgA is common in patients with multiple myeloma. IgG is the most abundant immunoglobulin in the blood and is typically less affected in multiple myeloma. IgM is the first antibody produced in response to an infection and is less likely to be deficient in this case. IgE is primarily involved in allergic responses and is not typically affected in multiple myeloma.

Question 8 of 9

While performing the admission assessment of a new client, the nurse observed that the client brought a bottle of over-the-counter pain medication to the hospital. The nurse failed to document this or remove the medication from the room. Subsequently, the client experienced a serious adverse drug reaction as a result of the interaction between this drug and one of the drugs that the client was prescribed in the hospital. This nurse may be guilty of what?

Correct Answer: A

Rationale: The correct answer is A: Malpractice. The nurse's failure to document and remove the over-the-counter medication, which led to a serious adverse drug reaction, constitutes malpractice. Malpractice refers to negligence or failure to provide the standard of care expected in a professional setting. In this case, the nurse's actions directly resulted in harm to the client, which is a clear example of malpractice. Incorrect Choices: B: Failure of duty to warn - This choice implies that the nurse had a duty to warn the client about the potential drug interaction, which may not necessarily be the case. The primary issue here is the nurse's failure to document and remove the medication, not a failure to warn. C: Assault - Assault involves intentional harm or threat of harm, which is not applicable in this scenario where the harm was due to negligence. D: Incompetence - While the nurse's actions may demonstrate incompetence, the more specific legal term for this situation would be malpractice, as it directly

Question 9 of 9

Upon entry of the patient to ER, the nurse must FIRST perform which nursing intervention?

Correct Answer: B

Rationale: The correct answer is B: Cleanse the bite with soap and running water. This is the first nursing intervention because it is crucial to prevent infection. Cleaning the bite area helps remove bacteria and debris, reducing the risk of infection. Injecting with rabies immune globulin (choice A) and rabies vaccine (choice C) should be done later as per protocol after assessing the situation. Administering pain reliever (choice D) is important but not the first priority in this scenario.

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