Nokea
A postpartum client exhibits signs of anxiety, restlessness, and palpitations. Which nursing intervention should be prioritized?
- A. Providing education on relaxation techniques
- B. Encouraging the client to practice deep breathing exercises
- C. Notifying the healthcare provider immediately
- D. Administering a benzodiazepine for anxiety relief
Correct Answer: C
Rationale: In a postpartum client exhibiting signs of anxiety, restlessness, and palpitations, it is essential to prioritize notifying the healthcare provider immediately. These symptoms could indicate a serious condition such as postpartum preeclampsia, postpartum hemorrhage, or postpartum cardiomyopathy, which require urgent medical attention. It is crucial to rule out any life-threatening conditions and ensure the client receives appropriate treatment promptly. While relaxation techniques and deep breathing exercises can be helpful for anxiety management in some cases, in this situation, the priority is to ensure the client's safety and well-being by seeking medical evaluation and intervention. Administering a benzodiazepine without consulting the healthcare provider first could potentially mask symptoms or interact with other medications the client may be taking, making it unsafe to proceed without professional guidance.
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While taking nursing history on Annie, what will be the response of the patient that indicates her present condition?
- A. She frequently experiences vertigo nausea and nystagmus when sitting.
- B. She has ear pain and discharge from the left ear when travelling.
- C. She has had impaired hearing since birth.
- D. Her hearing loss has become worse with each succeeding pregnancy
Correct Answer: A
Rationale: The response indicating Annie's present condition would be option A. This is because the symptoms mentioned in option A, such as experiencing vertigo, nausea, and nystagmus when sitting, point towards a vestibular disorder. These are symptoms commonly associated with conditions like Meniere's disease or vestibular neuritis, which can cause balance issues and feelings of dizziness. These symptoms are more indicative of Annie's current health status compared to the other options which focus on past or unrelated issues, such as ear pain during travel or impaired hearing since birth. The information provided in option A gives a more direct insight into Annie's present condition, making it the most appropriate response.
A nurse is caring for a patient with complex healthcare needs. What action by the nurse demonstrates effective care coordination?
- A. Working in isolation without consulting other healthcare providers
- B. Providing fragmented care without considering the patient's preferences
- C. Collaborating with interdisciplinary team members to develop a comprehensive care plan
- D. Focusing solely on completing tasks without addressing the patient's holistic needs
Correct Answer: C
Rationale: Collaborating with interdisciplinary team members to develop a comprehensive care plan demonstrates effective care coordination. In complex healthcare situations, involving various healthcare providers such as physicians, specialists, therapists, social workers, and others is crucial to ensure that all aspects of the patient's care are addressed holistically. By working together, healthcare professionals can share information, expertise, and insights to develop a well-rounded care plan that considers all aspects of the patient's needs. This collaborative approach helps promote better outcomes for the patient and enhances overall care coordination. It also helps to ensure that the patient's preferences and values are taken into account when developing the care plan.
Patient Haydee comes to the perinatal unit of Hospital DEE. Nurse Arcee does through SCREENING assessment. Which is the Least screening assessment to be used by the nurse/
- A. Physical examination
- B. Radiologic procedures
- C. Interview
- D. Laboratory review
Correct Answer: B
Rationale: Radiologic procedures are typically not used as the least screening assessment by nurses in a perinatal unit. The nurse's initial screening assessments usually focus on gathering information through techniques such as physical examination, interviews, and reviewing laboratory results. Radiologic procedures, such as X-rays or CT scans, are usually ordered by physicians once a more specific diagnostic need has been identified, based on the initial screening assessments performed by the nurse. Therefore, in this scenario, the least screening assessment to be used by the nurse would be radiologic procedures.
A patient with terminal illness expresses a desire to spend quality time with their family but feels guilty for being a burden. How should the palliative nurse respond?
- A. Dismiss the patient's feelings and reassure them that they are not a burden.
- B. Encourage the patient to focus on their own needs rather than worrying about others.
- C. Validate the patient's feelings of guilt and offer support to address their concerns.
- D. Suggest involving family members in caregiving tasks to alleviate the patient's guilt.
Correct Answer: C
Rationale: In this situation, the most appropriate response for the palliative nurse is to validate the patient's feelings of guilt and offer support to address their concerns. It is important to acknowledge the patient's emotions and help them navigate through their guilt in a compassionate and understanding manner. By validating their feelings, the nurse can create a safe space for the patient to express their concerns and work towards finding solutions to alleviate their guilt. This approach fosters trust and a therapeutic relationship between the patient and the nurse, ultimately promoting emotional well-being and facilitating open communication.
A patient is diagnosed with selective IgA deficiency, a primary immunodeficiency disorder. Which of the following complications is most commonly associated with this condition?
- A. Recurrent bacterial infections
- B. Severe combined immunodeficiency (SCID)
- C. Chronic granulomatous disease (CGD)
- D. Autoimmune hemolytic anemia
Correct Answer: A
Rationale: Selective IgA deficiency is a primary immunodeficiency disorder characterized by low or absent levels of immunoglobulin A (IgA) in the blood. Since IgA plays a crucial role in mucosal immunity and defense against pathogens at mucosal surfaces, individuals with this deficiency are more susceptible to recurrent bacterial infections, particularly of the respiratory and gastrointestinal tracts. In contrast, severe combined immunodeficiency (SCID) is a more severe immunodeficiency disorder affecting T and B lymphocytes, chronic granulomatous disease (CGD) is a disorder of phagocytes, and autoimmune hemolytic anemia is an autoimmune disease involving red blood cells, none of which are directly associated with selective IgA deficiency.