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When interacting with the parents of a SIDS infant, the nurse should attempt to assist the parents with:
- A. Encouraging the parents to have another baby.
- B. Encouraging the parents to remain stoic.
- C. Allaying feelings of guilt and blame.
- D. Learning how the event could have been prevented.
Correct Answer: C
Rationale: The correct answer is C: Allaying feelings of guilt and blame. When parents experience the loss of a SIDS infant, they often struggle with intense feelings of guilt and self-blame. The nurse's role is to provide emotional support and help alleviate these feelings. Choices A and B are incorrect as encouraging the parents to have another baby or to remain stoic is not appropriate or helpful in this situation. Choice D is also incorrect because focusing on how the event could have been prevented may exacerbate feelings of guilt and is not the immediate priority in supporting grieving parents.
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The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
- A. Nuchal rigidity
- B. Carotid bruit
- C. Jugular vein distention
- D. Palpable cervical lymph node
Correct Answer: B
Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Prothrombin time (PT)
- D. International normalized ratio (INR)
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level.
- B. Encourage incentive spirometry.
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic.
Correct Answer: D
Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.
A client who has a history of unstable angina is admitted to the emergency department with chest pain.
- A. Chest pain relieved by rest.
- B. Chest pain unrelieved after taking 3 sequential nitroglycerin tablets.
- C. Chest pain occurring only with exertion.
- D. Chest pain lasting less than 5 minutes.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?
- A. Risk for impaired skin integrity
- B. Fluid volume deficit
- C. Imbalanced nutrition: less than body requirements
- D. Activity intolerance
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.