While the nurse is taking yhe blood pressure, the patient suddenly stated."They are talking about me!". She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?

Correct Answer: B

Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.

Correct Answer: C

Rationale: An assumption is a belief or statement that is accepted as true without proof. In this case, the statement suggests a belief that the length of service does not affect the degree of patient safety practices among staff nurses, without providing evidence or data to support this claim. It is an assumption about the relationship between two variables without a proper basis or evidence to back it up, making it an example of an assumption.

Correct Answer: B

Rationale: Molluscum contagiosum is a viral skin infection caused by the poxvirus. It typically presents as multiple dome-shaped, translucent papules with central umbilication on the face and trunk. The lesions are usually asymptomatic but can be itchy. Molluscum contagiosum is a common infection in children but can also occur in adults, especially those who are immunocompromised. The lesions can gradually increase in number over time. Basal cell carcinoma, sebaceous hyperplasia, and keratoacanthoma do not typically present with the characteristic features of molluscum contagiosum.

Correct Answer: C

Rationale: Reflecting the patient's feelings and expressions is a therapeutic communication technique that involves mirroring back the patient's emotions and thoughts. By doing this, the nurse validates the patient's experiences and helps them explore their feelings further. This technique can enhance the patient's self-awareness and promote emotional expression, leading to a deeper understanding of their conflicting emotions. Offering advice (Option A) may not be as effective because the focus should be on helping the patient process their own emotions. Providing reassurance and false hope (Option B) can hinder the patient's emotional exploration and may lead to trust issues if the reality does not align with the false reassurance. Redirecting the conversation to a different topic (Option D) avoids addressing the patient's conflicting emotions, which is crucial for therapeutic communication and support.

Correct Answer: A

Rationale: After activating the emergency response system, the immediate priority in CPR is to begin chest compressions to support blood circulation. High-quality chest compressions are crucial in providing oxygen to vital organs, especially the brain, during cardiac arrest. Starting chest compressions promptly can improve the chances of survival for the person in need of CPR. Checking for breathing, performing abdominal thrusts, or assessing pulse should only be done after initiating chest compressions in the CPR sequence.

Correct Answer: A

Rationale: When collecting evidence from a rape victim, it is important to handle the victim's clothing properly to preserve any potential evidence. The preferred method is to remove the clothing and place them in a paper bag. Paper bags are used in order to prevent the alteration or degradation of any DNA evidence that may be present on the clothing. Paper bags allow the clothing to breathe and prevent the growth of mold or other contaminants that can occur in plastic bags or trash bags. Additionally, paper bags help preserve trace evidence such as fibers or hairs that may be crucial in the investigation of the case. It is essential to handle and store the clothing correctly to maintain the integrity of the evidence for the investigation and potential prosecution.

Correct Answer: B

Rationale: Quality Improvement is a systematic approach that aims to continually enhance the quality of services or products within an organization. The statement that is true of Quality Improvement is that it focuses on continually improving every process in the organization (Option B). This includes processes related to patient care, organizational structure, and all aspects of operations. Quality Improvement involves identifying areas for improvement, implementing changes, monitoring the effectiveness of those changes, and then making further refinements. By focusing on every process within the organization, Quality Improvement helps drive positive outcomes and ensures sustainable improvements in quality and performance.

Correct Answer: A

Rationale: Prior to a gastric lavage procedure, it is essential for the nurse to ensure the correct size of the nasogastric tube is selected. The appropriate size of the tube will allow for effective removal of the ingested poisonous substance during the procedure. Proper sizing also helps in preventing complications such as injury to the gastrointestinal tract or inadequate removal of the substance. This step is crucial for the safe and successful completion of gastric lavage. Reminding parents to be careful, obtaining informed consent immediately, or accusing them of negligence are not immediate responsibilities of the nurse in this context.

Correct Answer: D

Rationale: Bronze baby syndrome is the term used to describe the transient discoloration of a baby's skin while undergoing phototherapy treatment for jaundice. This phenomenon typically occurs in preterm infants and is believed to be caused by the breakdown of bilirubin into colored pigments during phototherapy. The discoloration can range from a bronze or brownish color to a grayish-green hue. One key characteristic of bronze baby syndrome is that the discoloration is reversible once phototherapy is complete and does not indicate any underlying health concerns. It is important for healthcare providers to be aware of this phenomenon to avoid unnecessary interventions or alarm to the caregivers.