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Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?
- A. Restrict visitors who irritate the client.
- B. Full rooming-in for the infant and mother.
- C. Supervised and guided visits with infant.
- D. Daily visits with her significant other.
Correct Answer: C
Rationale: The correct answer is C because supervised and guided visits with the infant allow the client to bond with her baby in a safe and structured environment, promoting maternal-infant attachment while ensuring the safety and well-being of both. Restricting visitors who irritate the client (choice A) may increase feelings of isolation and distress. Full rooming-in for the infant and mother (choice B) may overwhelm the client with severe postpartum depression. Daily visits with her significant other (choice D) may not directly address the client's need for bonding with her infant.
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What strategies are appropriate for preventing deep vein tharboirbm.cbomo/steisst (DVT) and pulmonary embolus (PE) in an at-risk patient? (Select all that apply.) WWW .THENURSINGMASTERY.COM
- A. Graduated compression stockings
- B. Heparin or low–molecular weight heparin
- C. Sequential compression devices
- D. Strict bed rest
Correct Answer: A
Rationale: The correct answer is A: Graduated compression stockings. These stockings help prevent blood from pooling in the legs, reducing the risk of DVT and PE. They improve circulation and reduce venous stasis. Option B, heparin, is used for treatment, not prevention. Option C, sequential compression devices, help prevent DVT but are not as effective as compression stockings. Option D, strict bed rest, can actually increase the risk of DVT by reducing blood flow.
The nurse is caring for a patient receiving benzodiazepine intermittently. What is the best way to administer such drugs?
- A. Medicate around the clock, rather than as needed, to en sure constant sedation.
- B. Administer the medications through the feeding tube to prevent complications.
- C. Give the highest allowable dose for the greatest effect.
- D. Titrate to a predefined endpoint using a standard sedat ion scale.
Correct Answer: D
Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects.
A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects.
B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications.
C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.
A patient receiving palliative care for advanced cancer reports fatigue and loss of appetite. Which intervention should the nurse prioritize?
- A. Encourage the patient to eat small, frequent meals.
- B. Administer prescribed appetite stimulants.
- C. Provide rest periods to reduce fatigue.
- D. Discuss the benefits of parenteral nutrition.
Correct Answer: C
Rationale: The correct answer is C: Provide rest periods to reduce fatigue. Prioritizing rest periods can help alleviate fatigue, a common symptom in patients with advanced cancer. Encouraging small, frequent meals (choice A) may not be effective if the patient has no appetite. Administering appetite stimulants (choice B) may not address the root cause of fatigue. Discussing parenteral nutrition (choice D) is not the priority as it does not directly address the fatigue and loss of appetite reported by the patient. Rest is essential for symptom management and overall well-being in palliative care.
When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.
The nurse is discussing the role of hospice care with a patient and family. Which statement by the nurse accurately describes hospice care?
- A. Hospice care aims to cure serious illnesses through specialized treatments.
- B. Hospice care provides support and comfort for patients at the end of life.
- C. Hospice care is only for patients with cancer-related illnesses.
- D. Hospice care focuses primarily on extending life expectancy.
Correct Answer: B
Rationale: The correct answer is B because hospice care indeed focuses on providing support and comfort for patients at the end of life. This is achieved through pain management, emotional support, and enhancing quality of life. Choice A is incorrect because hospice care does not aim to cure serious illnesses but rather to provide comfort and care. Choice C is incorrect as hospice care is not limited to patients with cancer but is available to individuals with various terminal illnesses. Choice D is incorrect as hospice care does not focus on extending life expectancy but rather on improving the quality of life during the end-of-life period.