A 29-year-old client is admitted for a hysterectomy and is expressing concern regarding the procedure. Shortly into the preoperative teaching, the client complains of a tightness in the chest, feelings of suffocation, light-headedness, and tingling in the hands. The client's respirations are rapid and deep. The nursing assessment reveals that this client is:

Correct Answer: D

Rationale: Classic symptoms of a heart attack include a heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may also be present. However, the client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, lack of airflow between the nose and mouth, and absent breath sounds. A tightness in the chest, feelings of suffocation, light-headedness, tingling in the hands, and rapid deep respirations are signs and symptoms of hyperventilation, which is almost always a manifestation of anxiety.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D, the homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin. This patient is likely experiencing severe dehydration and hyperthermia, which are life-threatening conditions requiring immediate attention. Dehydration can lead to electrolyte imbalances and organ failure, while hyperthermia can progress to heat stroke. Option A, the elderly person with dizziness and syncope after sun exposure, may have heat exhaustion, but the symptoms in option D indicate a more critical condition. Option B, the marathon runner with leg cramps and other symptoms, likely has heat exhaustion, which is serious but not as immediately life-threatening as the conditions in option D. Option C, the homemaker with signs of heat exhaustion due to a broken air conditioner, also requires attention but is not as critical as the altered mental status and poor coordination seen in option D. In the context of medical-surgical nursing, it is essential to prioritize patients based on the severity and acuity of their conditions. This question highlights the importance of recognizing critical signs and symptoms that require immediate intervention to prevent further deterioration and potential life-threatening outcomes. Nurses must be able to quickly assess and prioritize patients based on the urgency of their needs to provide timely and appropriate care.

Correct Answer: C

Rationale: In the context of medical-surgical nursing practice, the most appropriate task for an LPN/LVN is to provide emotional support and supportive communication, which is option C. This is because LPNs/LVNs are trained to deliver holistic care to patients, which includes addressing their emotional well-being and providing psychological support during times of distress or uncertainty. LPNs/LVNs have the skills to engage in therapeutic communication and offer empathy to patients in need. Option A, assessing immediate emotional state and physical injuries, is typically within the scope of practice of a registered nurse or advanced practice nurse who has the training and licensure to perform comprehensive assessments and make clinical judgments. Option B, collecting forensic evidence like hair samples and saliva swabs, requires specialized training and is usually carried out by forensic nurses or trained technicians. Option D, ensuring the 'chain of custody' is maintained, is a legal and procedural task that is often the responsibility of law enforcement personnel or individuals specifically trained in forensic protocols. LPNs/LVNs are not typically involved in maintaining the chain of custody in a healthcare setting. In an educational context, it is important for nursing students to understand the scope of practice for different levels of nursing personnel. By selecting option C as the most appropriate task for an LPN/LVN, students can grasp the importance of providing holistic care and emotional support as integral components of nursing practice. This question reinforces the need for clear understanding of roles and responsibilities within the healthcare team.

Correct Answer: C

Rationale: In the context of medical-surgical nursing, delegating tasks appropriately is crucial for optimal patient care. The most appropriate task to delegate to a nursing assistant among the options provided is "Assist with postmortem care (Option C)." This task involves non-invasive care after a patient has passed away and can be safely and effectively performed by a nursing assistant under the supervision of a registered nurse. Option A, escorting the family to a place of privacy, requires sensitivity, communication skills, and potentially providing emotional support to the family members. This task is more suited for a registered nurse who has the training and expertise to handle such delicate situations effectively. Option B, going with the organ donor specialist to talk to the family, involves complex discussions about organ donation that require specialized knowledge and training. This task should be handled by a healthcare professional with specific expertise in organ donation and counseling. Option D, assisting the family to collect belongings, also involves emotional support and sensitivity, as well as potential interactions that may require medical knowledge. This task is best performed by a healthcare professional who can address any medical concerns or emotional needs that may arise during the process. Educationally, understanding the principles of delegation in nursing is essential for providing safe and effective care. Nurses must consider factors such as the complexity of the task, the skills and training of the assistive personnel, and the needs of the patient and family when delegating responsibilities. By selecting the appropriate tasks for delegation, healthcare providers can optimize teamwork, efficiency, and patient outcomes.

Correct Answer: A

Rationale: In this scenario, the priority nursing diagnosis is option A: Risk for Infection related to organisms specific to cat bites. The rationale behind this choice is that cat bites have a high risk of infection due to the bacteria present in a cat's mouth. Infections from cat bites can lead to serious complications if not addressed promptly, including cellulitis, abscess formation, and even septicemia. Option B, Impaired Skin Integrity related to puncture wounds, while important, is not the priority in this case because the risk of infection takes precedence over skin integrity. Infections can quickly worsen and become systemic if not managed effectively. Option C, Ineffective Health Maintenance related to immunization status, is not the priority at this moment because the immediate concern is addressing the risk of infection from the cat bite. While immunization status is important for overall health, it is not the most urgent issue in this context. Option D, Risk for Impaired Mobility related to potential tendon damage, is also not the priority compared to the risk of infection. Mobility issues can be addressed once the infection risk is managed, as infections can have life-threatening implications if not dealt with promptly. In an educational context, this question highlights the importance of prioritizing nursing diagnoses based on the immediate needs of the patient. Understanding the urgency of different health concerns and being able to prioritize them is a crucial skill for nurses in providing effective and timely care to patients.