The patient comes to the hospital with a variety of symptoms.
Which symptom will the nurse assess first?

Joint stiffness after sitting for a long period of time.

Nausea with a small amount of vomitus earlier this morning.

A rash that developed after the second dose of antibiotics.

Shortness of breath with audible wheezing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Joint stiffness after sitting for a long period of time, often referred to as "gelling," is a common symptom associated with inflammatory joint conditions like osteoarthritis or rheumatoid arthritis. While it can be a source of discomfort and reduced mobility, it typically does not indicate an immediate life-threatening situation. The body's synovial fluid thins with inactivity, leading to increased friction and stiffness upon movement.

Choice B rationale

Nausea with a small amount of vomitus suggests gastrointestinal upset. While it can cause discomfort and lead to dehydration if persistent, it is generally not an acute emergency unless accompanied by severe abdominal pain, signs of dehydration, or other systemic symptoms. The body's chemoreceptor trigger zone can be activated by various stimuli, leading to the sensation of nausea and subsequent emesis.

Choice C rationale

A rash that developed after a second dose of antibiotics could indicate an allergic reaction, which ranges from mild to severe. While allergic reactions require assessment and intervention, they are not immediately life-threatening unless accompanied by signs of anaphylaxis such as angioedema or respiratory distress. This hypersensitivity reaction involves the immune system's response to the drug as an antigen.

Choice D rationale

Shortness of breath with audible wheezing indicates respiratory distress, which is a critical and potentially life-threatening condition. Wheezing suggests airway narrowing, which impedes oxygen-carbon dioxide exchange. Immediate assessment and intervention are required to prevent respiratory arrest and ensure adequate oxygenation to vital organs. This physiological response reflects bronchoconstriction and inflammation, severely compromising ventilation.

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Correct Answer is B

Explanation

Choice A rationale

Immediately before menstruation, hormonal fluctuations, particularly increased estrogen levels, can lead to breast swelling and tenderness. This physiological engorgement can obscure subtle lumps or changes, making accurate palpation difficult and potentially leading to false positives or missed abnormalities during self-examination, thereby reducing its efficacy.

Choice B rationale

Days 4-7 of the menstrual cycle, specifically post-menstruation, are optimal for breast self-examination because hormonal influences are at their lowest point. Estrogen and progesterone levels are minimal, resulting in the least breast tenderness and swelling. This makes breast tissue softer and less nodular, facilitating the detection of any new or subtle changes.

Choice C rationale

During ovulation, estrogen levels are elevated, which can cause some degree of breast fullness and tenderness due to glandular changes. This hormonal influence can make it more challenging to distinguish normal breast tissue from suspicious lumps, potentially leading to inaccurate findings and reducing the sensitivity of the self-examination process.

Choice D rationale

While consistency is important, simply choosing any same day of the month without regard to the menstrual cycle can lead to less effective examinations. Hormonal fluctuations throughout the cycle significantly impact breast tissue consistency. A fixed day may coincide with breast swelling or tenderness, hindering accurate assessment and potentially masking abnormalities, thereby reducing detection rates.

Correct Answer is ["1200"]

Explanation

Step 1::00 pm in military time is 1200. The PM hours in the 12-hour clock align with the 12th hour in military time for 12: pm. Answer: 1200.

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The patient comes to the hospital with a variety of symptoms. Which symptom will the nurse assess first?

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Naxlex Comprehensive Predictor Exams

During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate?

Correct Answer is B

Explanation

Convert 12:00 pm to military time.

Correct Answer is ["1200"]

Explanation

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The patient comes to the hospital with a variety of symptoms.
Which symptom will the nurse assess first?