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A postpartum client reports severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Assessing blood pressure and other vital signs
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to assess the client's blood pressure and other vital signs. The client's symptoms of severe headache, visual disturbances, and epigastric pain could be indicative of preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Checking the blood pressure and other vital signs will help determine if the client's symptoms are related to abnormal blood pressure levels, which is critical in identifying and managing hypertensive disorders in postpartum clients. Once the assessment is completed, appropriate medical interventions can be initiated promptly if necessary.
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Which of the following is a primary consideration in planning for her care?
- A. To prevent problems related to immobility
- B. To prevent infection
- C. Planning for client`s eventual inability communicate
- D. To prevent complications
Correct Answer: A
Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.
When a health facility formulates its Vision- Mission to guided Management and health personnel in the work place is what part of quality-standards?
- A. Human resource management
- B. Leadership and management
- C. Patient care standards
- D. Organizational ethics
Correct Answer: B
Rationale: The formulation of a vision and mission statement in a health facility is an essential aspect of leadership and management. A well-crafted vision and mission statement provide the organization with a clear direction and purpose, guiding management and health personnel in their daily activities. It helps in aligning individual goals with organizational objectives, fostering teamwork, and enhancing overall performance. Effective leadership and management ensure that the vision and mission are communicated effectively, understood by all stakeholders, and implemented throughout the organization to achieve quality standards. By setting the tone for organizational culture and values, leadership and management play a crucial role in shaping the quality of care and services provided by the health facility.
Which of the following is NOT included among the factors that should be considered by the nurse or the pregnant woman in interpreting results of pregnancy test?
- A. Last menstrual period
- B. Type of pregnancy test
- C. Previous pregnancy
- D. Menstrual cycle length
Correct Answer: B
Rationale: The type of pregnancy test is not a factor that should be considered by the nurse or the pregnant woman in interpreting the results of a pregnancy test. Factors such as the last menstrual period, previous pregnancy history, and menstrual cycle length play a crucial role in determining the reliability and accuracy of the pregnancy test results.
A patient with suspected acute exacerbation of asthma presents with severe dyspnea, accessory muscle use, and inability to speak in full sentences. Which of the following interventions is most appropriate for assessing the severity of the patient's asthma exacerbation and guiding management decisions?
- A. Peak expiratory flow rate (PEFR) measurement
- B. Arterial blood gas (ABG) analysis
- C. Chest X-ray
- D. Clinical assessment using standardized severity scores
Correct Answer: D
Rationale: In the scenario described, the patient is presenting with severe symptoms of acute exacerbation of asthma, including severe dyspnea, accessory muscle use, and inability to speak in full sentences. In such cases, the most appropriate intervention for assessing the severity of the asthma exacerbation and guiding management decisions is a clinical assessment using standardized severity scores.
The psychiatric diagnosing of patients is a morally charged issue and the assigning of diagnosis may be an ethical issue. The role of the nurse in diagnosing psychiatric patient is important because nurses are _______.
- A. collaborators in the diagnostic process
- B. planners of psychiatric nursing care
- C. knowledgeable in the field of psychiatry due to extensive clinical experience
- D. Competent by virtue of their educational preparation
Correct Answer: A
Rationale: Nurses play a crucial role as collaborators in the diagnostic process of psychiatric patients. While nurses themselves do not diagnose psychiatric conditions, they work closely with other healthcare providers such as psychiatrists and psychologists in assessing and monitoring patients' mental health status. Nurses gather valuable information, observe patients' behaviors, and communicate effectively with the healthcare team to contribute to the overall diagnostic process. By actively participating in assessments and evaluations, nurses help ensure accurate diagnoses and appropriate treatment plans for psychiatric patients.