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Nurse Cris received information from some community residents who suspect that a neighbor ls abusing his young child. Which should be the PRIORITY nursing action ?
- A. Report the police authorities.
- B. Notify the social worker.
- C. Ignore the information
- D. Validate the information
Correct Answer: A
Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.
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A patient with a history of chronic obstructive pulmonary disease (COPD) is prescribed prednisone for an acute exacerbation. Which instruction is important for the nurse to include in patient education about prednisone therapy?
- A. "Take prednisone with antacids to minimize gastrointestinal upset."
- B. "Avoid abruptly stopping prednisone therapy."
- C. "Increase your intake of potassium-rich foods while taking prednisone."
- D. "Prednisone may cause weight loss, so monitor your weight regularly."
Correct Answer: B
Rationale: It is crucial for patients with COPD who are prescribed prednisone to be educated about the importance of not abruptly stopping the medication. Prednisone is a type of corticosteroid that should be tapered off gradually under the guidance of a healthcare provider to prevent potential withdrawal symptoms and adrenal insufficiency. Suddenly stopping prednisone can lead to serious adverse effects, including fatigue, weakness, joint pain, fever, dizziness, and potentially life-threatening complications. Therefore, adherence to the prescribed tapering schedule is essential to ensure the safe and effective management of COPD exacerbations with prednisone therapy.
Given her problems of hyper vigilance and worry that something terrible will happen to her child, nursing interventions should be aimed at addressing her needs for _______.
- A. Love and belongingness
- B. psychological security
- C. biological integrity
- D. self-esteem
Correct Answer: B
Rationale: Nursing interventions should be aimed at addressing the mother's needs for psychological security. Hyper vigilance and excessive worry about her child's safety indicate a lack of security in her mind. By providing support, reassurance, and education, nurses can help the mother feel more secure in her role as a parent and reduce her feelings of anxiety and distress. Establishing trust and building a therapeutic relationship can also contribute to enhancing the mother's psychological security and well-being.
While preparing the surgical site, the nurse notices that the skin preparation solution has expired. What should the nurse do?
- A. Use the expired solution as it is still effective
- B. Document the expiration date in the patient's chart
- C. Discard the expired solution and obtain a new one
- D. Dilute the solution with sterile water to extend its shelf life
Correct Answer: C
Rationale: Using an expired skin preparation solution can compromise the safety and effectiveness of the surgical site cleansing. Expired solutions may have reduced efficacy or could cause adverse reactions due to chemical breakdown over time. Therefore, it is essential for the nurse to discard the expired solution and obtain a new one to ensure proper sanitation and reduce the risk of complications during the surgical procedure. It is important to adhere to proper protocols and guidelines in healthcare settings to maintain patient safety and optimal outcomes.
A patient with advanced cancer experiences dyspnea and anxiety during episodes of breathlessness. Which intervention should the palliative nurse prioritize to address the patient's symptoms?
- A. Administer oxygen therapy to relieve dyspnea.
- B. Teach the patient pursed-lip breathing techniques.
- C. Recommend opioid medications for symptom management.
- D. Refer the patient to a respiratory therapist for breathing exercises.
Correct Answer: C
Rationale: Opioid medications are considered the first-line pharmacological treatment for dyspnea in palliative care patients with advanced cancer. Opioids help relieve dyspnea by reducing respiratory drive and the sensation of breathlessness, providing effective symptom management. In this case, addressing the patient's dyspnea with opioid medications would likely also help alleviate their anxiety related to breathlessness. Administering oxygen therapy (choice A) may not be effective at relieving dyspnea in this situation, as dyspnea in advanced cancer patients is often not primarily due to low oxygen levels. Teaching pursed-lip breathing techniques (choice B) and referring the patient to a respiratory therapist for breathing exercises (choice D) may be helpful complementary interventions, but opioid medications should be the priority for symptom management.
A woman in active labor is diagnosed with a prolapsed umbilical cord. What is the priority nursing action?
- A. Elevate the mother's hips to relieve pressure on the cord.
- B. Prepare for immediate cesarean section.
- C. Administer intravenous fluids rapidly.
- D. Perform a vaginal examination to assess cervical dilation.
Correct Answer: B
Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.