RN exams medical-surgical practice questions set 26

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Providing education on techniques to improve latch and milk transfer should be prioritized to support successful breastfeeding in this situation. Newborns who are macrosomic (large for gestational age) may have difficulties latching due to their size and may require additional support to effectively breastfeed. By educating the postpartum client on proper latch techniques and milk transfer, the nurse can help optimize the breastfeeding experience for both the mother and baby. This intervention focuses on addressing the specific concerns related to the infant's size and aims to promote successful breastfeeding despite potential challenges. As such, recommending supplemental formula feedings, encouraging the client to avoid breastfeeding, or immediately referring to a lactation consultant may not directly address the immediate need for support in improving breastfeeding in this situation.

Correct answer:

Autonomic dysreflexia is a life-threatening condition commonly seen in clients with spinal cord injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure due to a noxious stimulus below the level of injury, often a distended bladder. The exaggerated sympathetic response leads to vasoconstriction, resulting in symptoms such as profuse diaphoresis (sweating) and a severe, pounding headache. These symptoms are the body's attempt to lower blood pressure. Complaints of chest pain and shortness of breath (Choice A) are not typical findings in autonomic dysreflexia. Hypotension and venous pooling (Choice B) are opposite manifestations of autonomic dysreflexia, which is characterized by hypertension. Pain and burning sensation upon urination and hematuria (Choice D) are indicative of a urinary tract infection and not specific to autonomic dysreflexia.

Correct answer:

The correct answer is C because observing the patient's body build and muscle configuration provides initial information about the patient's overall musculoskeletal health. This step allows the nurse to assess for any abnormalities, such as muscle atrophy or asymmetry, which can indicate underlying musculoskeletal issues. It also helps in identifying any deformities or structural abnormalities. Choice A is incorrect because having the patient move the extremities against resistance comes later in the assessment process to evaluate muscle strength. Choice B is incorrect as feeling for crepitus during joint movement is a specific assessment for joint health and does not address the overall musculoskeletal system. Choice D is incorrect as checking active and passive range of motion for the extremities is typically done after observing the patient's body build and muscle configuration.

Correct answer:

In a primiparous patient who complains of unrelieved perineal pain on the first postpartum day, Nurse Kayla should assess for a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can cause significant pain and discomfort. It can be a result of trauma during delivery or due to a blood vessel rupture. This condition requires prompt assessment and intervention to prevent complications such as infection or excessive bleeding. Vaginal laceration would typically be identified during the delivery process and would have been repaired by the healthcare provider. History of drug abuse, while important to know for overall patient care, is not as relevant in this immediate postpartum pain assessment. Puerperal infection usually presents with other signs such as fever, foul-smelling discharge, and uterine tenderness, which are not mentioned in this scenario.

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The correct answer is D: Ask the patient to describe the impact of psoriasis on quality of life. This is the first action the nurse should take to understand the patient's perspective, feelings, and how psoriasis is affecting their daily life. By doing so, the nurse can assess the severity of the social withdrawal and emotional impact, which can guide further interventions. Choice A is incorrect because enrolling in a worker-retraining program does not address the immediate social withdrawal and emotional impact due to psoriasis. Choice B is incorrect as encouraging the patient to volunteer for community projects may not be suitable or effective in addressing the patient's current emotional distress. Choice C is incorrect because suggesting cosmetics to cover the lesions only focuses on the physical appearance and does not address the underlying emotional and social issues.

Correct answer:

One of the major differences between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that Hodgkin's lymphoma is considered potentially curable, while non-Hodgkin's lymphoma is typically not curable. Hodgkin's lymphoma is characterized by the presence of Reed-Sternberg cells, which are not found in non-Hodgkin's lymphoma. Additionally, Hodgkin's lymphoma tends to spread in a more orderly and predictable manner through the lymph nodes, making it easier to treat and potentially cure with the appropriate combination of chemotherapy, radiation therapy, and stem cell transplant. On the other hand, non-Hodgkin's lymphoma is a diverse group of lymphomas that can vary greatly in presentation, behavior, and response to treatment, with some subtypes being more aggressive and resistant to treatment. Therefore, the potential for cure is higher in Hodgkin's lymphoma compared to non-Hodgkin's lymph

Correct answer:

The correct answer is C because observing the patient's body build and muscle configuration provides initial information about the patient's overall musculoskeletal health. This step allows the nurse to assess for any abnormalities, such as muscle atrophy or asymmetry, which can indicate underlying musculoskeletal issues. It also helps in identifying any deformities or structural abnormalities. Choice A is incorrect because having the patient move the extremities against resistance comes later in the assessment process to evaluate muscle strength. Choice B is incorrect as feeling for crepitus during joint movement is a specific assessment for joint health and does not address the overall musculoskeletal system. Choice D is incorrect as checking active and passive range of motion for the extremities is typically done after observing the patient's body build and muscle configuration.

Correct answer:

Elimination,' as this function describes the skin's role in excreting water, electrolytes, and nitrogenous wastes through sweat. Sweat glands produce sweat, a mixture containing these substances, aiding in waste removal and electrolyte balance, albeit in small amounts compared to kidneys. 'Protection' refers to the skin's barrier against pathogens and injury, not excretion. 'Sensation' involves nerve endings detecting stimuli, unrelated to waste. 'Regulation' covers temperature control via sweating or vasoconstriction, but the question specifies excretion, not thermoregulation. Elimination uniquely fits, as it's a recognized skin function in physiology, crucial for nursing knowledge in fluid balance and patient assessment e.g., excessive sweating might signal electrolyte loss. This specificity distinguishes 'Elimination' as the precise answer, aligning with the skin's excretory role.

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Rationale: Robert Koch is correctly paired with developing techniques to grow pure bacterial cultures. Koch's work laid the foundation for bacteriology and allowed for the isolation and identification of specific disease-causing bacteria. This technique, known as Koch's postulates, revolutionized the field of microbiology by linking specific pathogens to specific diseases. Summary: A: Louis Pasteur - Incorrect. While Pasteur is known for his work in vaccination and pasteurization, the provided accomplishment is associated with Edward Jenner, not Pasteur. B: Paul Ehrlich - Incorrect. Ehrlich is known for his work on immunology and coined the term "magic bullet," but he did not identify lymphocytes as cells mediating adaptive immunity. C: MacFarlane Burnet - Incorrect. Burnet is known for his clonal selection theory, not the side-chain theory of antibodies as described in the choice.

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Step 1: When a bird is transferred to a colder environment (10ºC), its body temperature tends to drop. Step 2: To maintain its body temperature, the bird needs to conserve and produce more heat internally. Step 3: This increased conservation and production of heat help the bird to keep its body temperature at the original constant level. Step 4: Therefore, option D is correct as it accurately describes the physiological response of a bird to a decrease in environmental temperature. Summary: Option A is incorrect because dissipation of heat does not maintain the body temperature but rather leads to a decline. Option B is incorrect as it suggests a decline without considering the bird's ability to regulate its temperature. Option C is incorrect as increased production and conservation of heat would not result in a rise above normal body temperature in response to a colder environment.