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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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The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has:
- A. acute kidney injury from a prerenal condition.
- B. acute kidney injury from postrenal obstruction.
- C. intrarenal disease, probably acute tubular necrosis.
- D. a urinary tract infection.
Correct Answer: C
Rationale: The correct answer is C: intrarenal disease, probably acute tubular necrosis. The patient's symptoms of general malaise, fatigue, decreased urinary output, along with the presence of coarse, muddy brown granular casts and hematuria in the urinalysis indicate kidney damage. Acute tubular necrosis is a common cause of acute kidney injury characterized by damage to the renal tubules, leading to impaired kidney function. The presence of granular casts and hematuria suggests tubular injury and bleeding within the kidney. Choices A and B are incorrect as they refer to prerenal and postrenal causes of kidney injury, respectively, which do not align with the patient's symptoms and urinalysis findings. Choice D is incorrect as a urinary tract infection would typically present with different symptoms and urinalysis findings.
A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?
- A. Contact a grief counselor as soon as possible.
- B. Cry along with the patient’s family members.
- C. Leave the home as soon as possible to allow the family to grieve privately.
- D. Consider whether working in hospice is desirable because patient losses are common.
Correct Answer: B
Rationale: The correct answer is B: Cry along with the patient’s family members. This action demonstrates empathy and support for the family's grief, showing that the nurse acknowledges and shares their feelings. It can help the family feel understood and supported during a difficult time. By crying with the family, the nurse can validate their emotions and provide comfort without intruding on their personal space. This approach fosters a sense of connection and trust between the nurse and the family, enhancing the quality of care provided.
Incorrect Choices:
A: Contact a grief counselor as soon as possible - This choice may be premature and could come across as impersonal or distancing in the immediate aftermath of the patient’s death.
C: Leave the home as soon as possible - This choice would be insensitive and could make the family feel abandoned in their time of need.
D: Consider whether working in hospice is desirable because patient losses are common - This choice is inappropriate as it suggests the nurse should reconsider their career choice based on emotional reactions,
The family members are excited about being transferring t heir loved one from the critical care unit to the intermediate care unit. However, they are also fearful of the change in environment and nursing staff. To reduce relocation stress, the nurse ca n implement what intervention? (Select all that apply.)
- A. Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit.
- B. Contacting the primary care provider to see if the patient can stay one additional day in the critical care unit so that the family can adjus t better to the idea of a transfer.
- C. Ensuring that the patient will be located near the nurse ’s station in the new unit.
- D. Inviting the nurse who will be assuming the patient’s care to meet with the patient and family in the critical care unit prior to transfer.
Correct Answer: A
Rationale: The correct answer is A (Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit) because it helps familiarize the family with the new environment, alleviating their fears. The tour allows them to see where their loved one will be cared for, meet the nursing staff, and ask any questions they may have. This intervention promotes a smooth transition, reduces anxiety, and builds trust.
Choice B is incorrect because delaying the transfer doesn't address the fear of change and can prolong stress. Choice C is incorrect as proximity to the nurse's station may not necessarily reduce relocation stress for the family. Choice D is incorrect because meeting the new nurse in the current unit may not provide the same level of comfort and preparation compared to physically visiting the new unit.
A nurse who works in an intermediate care unit has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leade r by staff members and that leadership style is contributing to turnover. The nurse asks to be involved in developing new guidelines to prevent pressure ulcers in the patient populat ion. The nurse manager suggests that the nurse has not yet had enough experience to be on tahbierb p.croemv/teenstt ion task force. This situation and setting is an example of what form of ineffec tive leadership?
- A. Creating a barrier to inter-staff communication.
- B. Supporting a work environment that is unhealthy.
- C. Displaying ineffective decision making.
- D. Demonstrating nursing practice that is not evidence-based.
Correct Answer: C
Rationale: The correct answer is C: Displaying ineffective decision making. In this scenario, the nurse manager's decision to exclude the nurse from participating in developing new guidelines is an example of ineffective decision making. By dismissing the nurse's request based on lack of experience rather than considering their input and involvement, the manager is not utilizing the nurse's expertise and potentially missing out on valuable insights. This decision reflects a lack of inclusivity, collaboration, and respect for the nurse's professional growth and potential contributions. The other choices are not directly applicable in this context as the core issue lies in the manager's decision-making process.
The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
- A. Apply a pressure dressing to the insertion site.
- B. Ensure all tubing connections are tightened.
- C. Obtain a portable x-ray to confirm placement.
- D. Restrain the affected extremity for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Obtain a portable x-ray to confirm placement. This is the priority intervention because it ensures the arterial line is correctly positioned, reducing the risk of complications such as dislodgement or improper placement. Applying a pressure dressing (choice A) may be necessary but is not the priority. Ensuring tubing connections are tightened (choice B) is important for preventing leaks but does not address placement. Restraining the affected extremity (choice D) is unnecessary and can lead to complications. The x-ray confirms correct placement, ensuring accurate monitoring and treatment.