A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving:

Correct Answer: D

Rationale: The correct answer is D because the patient has a high-risk wound (tissue avulsion) and no documented prior tetanus vaccination. TIG provides immediate passive immunity to tetanus, while Tdap stimulates active immunity. TIG covers immediate needs, while Tdap ensures long-term immunity. Choice A (TIG only) does not provide long-term immunity. Choice B (TIG and Td) does not include pertussis coverage, which Tdap (Choice D) does. Choice C (Tdap only) does not cover immediate needs as TIG does.

Correct Answer: D

Rationale: The correct answer is D because brushing off any visible powder on the skin and clothing is the first step in managing exposure to powdered lime. This action helps to remove the source of exposure and prevent further absorption through the skin. It is crucial to prevent additional contact and reduce the risk of further harm. Obtaining vital signs (choice A) and a complete blood count (choice B) can be important but should come after the initial decontamination. Decontaminating the patient by showering with water (choice C) is not recommended for lime exposure as it can react with water and cause further injury.

Correct Answer: B

Rationale: The correct answer is B because sitting at the bedside and asking if there is anything the patient needs demonstrates empathy and support. It allows the patient to express their concerns and fears, providing emotional comfort. It shows the nurse is actively listening and willing to help address any immediate needs or concerns. Choice A is incorrect because it dismisses the patient's feelings and may come across as invalidating. Choice C is incorrect because insisting that family members remain may not be what the patient needs at that moment and could cause additional stress. Choice D is incorrect because it does not address the patient's emotional distress and may not be true in the context of terminal illness.

Correct Answer: C

Rationale: The correct answer is C because the patient with AIDS-related dementia requires palliative care and pain management, which are key components of hospice care. This patient is likely in the terminal stage of their illness and would benefit from the comprehensive support provided by hospice services. Choice A is incorrect because the patient's children's inability to discuss dying issues does not necessarily indicate a need for hospice care. Choice B is incorrect as chronic severe pain due to spinal arthritis is not a sole criterion for hospice referral. Choice D is incorrect as advanced liver failure alone does not automatically qualify a patient for hospice care.

Correct Answer: C

Rationale: The correct answer is C because maintaining hydration and nutrition until the patient dies is not always appropriate in end-of-life care, as some patients may be unable to tolerate oral intake or may be close to the end of life where artificial nutrition and hydration may not provide benefit and may even cause discomfort. Explanation: A: A is correct because terminally ill patients may indeed benefit from continuous pain management to ensure comfort. B: B is correct because hospice care is typically initiated when curative treatment is no longer effective and focuses on providing comfort and quality of life. D: D is correct because emotional support is crucial in end-of-life care to address the patient's psychological well-being and provide comfort. In summary, choice C is incorrect as it does not consider individual patient needs and preferences in end-of-life care.