A 48 year-old client with chronic alcoholism is admitted to the hospital. The nurse would anticipate that the client may be deficient in which vitamins?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Vitamin B and vitamin C. When a client has chronic alcoholism, they are at risk for malnutrition due to poor dietary intake, impaired absorption, and increased excretion of essential nutrients. Vitamin B deficiencies are common in individuals with chronic alcoholism due to poor dietary intake, impaired absorption in the gastrointestinal tract, and increased excretion by the kidneys. Vitamin B deficiencies can lead to neurological symptoms, anemia, and other health issues. Vitamin C deficiency can occur in individuals with chronic alcoholism due to poor dietary intake and impaired absorption. Vitamin C deficiency can lead to weakened immune function, impaired wound healing, and scurvy. The other options are incorrect because: - Option B (Vitamin D and vitamin E): While chronic alcoholism can also impact the absorption and utilization of these vitamins, deficiencies in Vitamin B and C are more common and critical in this context. - Option C (Vitamin K and vitamin A): While these vitamins play important roles in health, they are not typically the primary deficiencies seen in individuals with chronic alcoholism. - Option D (Vitamin A and vitamin E): Similar to Option C, deficiencies in these vitamins are not as common or as critical as Vitamin B and C deficiencies in individuals with chronic alcoholism. Educationally, understanding the specific nutrient deficiencies associated with chronic alcoholism is crucial for nurses caring for these clients to provide appropriate nutritional support and prevent further health complications. This knowledge helps in developing comprehensive care plans tailored to the individual's needs and promoting better health outcomes.

Correct Answer: C

Rationale: In caring for a client with a chest tube post-surgery, it is crucial for the chest drainage system to remain below chest level to ensure proper drainage of fluids by gravity. Option C is the correct answer because if the drainage system is positioned above the chest, it can lead to backflow of fluids into the chest cavity, potentially causing complications like pneumothorax or hemothorax. Option A is incorrect because securely taping the chest tube at the insertion site is a proper procedure to prevent dislodgement. Option B is incorrect as having the water seal chamber filled to the correct level ensures proper functioning of the system. Option D is incorrect as the absence of air leaks is important to maintain the system's integrity. Educationally, understanding the correct positioning of a chest drainage system is vital for nurses caring for post-operative patients with chest tubes to prevent complications and ensure optimal recovery. Nurses must possess the knowledge and skills to assess, maintain, and troubleshoot chest drainage systems effectively to provide safe and effective care to their patients.

Correct Answer: B

Rationale: In the context of a client who is bedridden after a stroke, the most important nursing intervention in preventing pressure ulcers is to reposition the client every 2 hours (Option B). This is crucial as frequent repositioning helps to relieve pressure on bony prominences, improves circulation, and reduces the risk of tissue ischemia and subsequent ulcer formation. Applying lotion every 4 hours (Option A) may help with skin hydration but does not address the root cause of pressure ulcer development. Elevating the head of the bed 30 degrees (Option C) is important for preventing aspiration in some cases but does not directly prevent pressure ulcers. Massaging the skin at least twice a day (Option D) can actually exacerbate the risk of pressure ulcers by increasing friction and shearing forces on the skin. In an educational context, understanding the rationale behind the correct intervention reinforces the importance of evidence-based practice in nursing care. It highlights the significance of proactive measures to prevent complications such as pressure ulcers, emphasizing the role of nursing interventions in maintaining patient skin integrity and overall well-being.

Correct Answer: C

Rationale: In this scenario, the correct response (option C) demonstrates empathy and a focus on problem-solving. By acknowledging the UAP's feelings and suggesting a collaborative approach to address the challenging situation, the nurse validates the UAP's emotions and fosters a supportive environment. This response promotes open communication, teamwork, and a patient-centered approach to care. Option A is incorrect because it dismisses the UAP's feelings and places the blame on the client, lacking empathy and problem-solving. Option B is not ideal as it puts the responsibility solely on the nurse to resolve the issue, missing the opportunity to involve the UAP in finding a solution collaboratively. Option D is inappropriate as it ignores the UAP's emotional distress and suggests avoiding the problem, which does not address the underlying issue or support the UAP effectively. Educationally, this scenario highlights the importance of effective communication, teamwork, and empathy in healthcare settings. It emphasizes the need for nurses to support and empower their colleagues, fostering a positive work environment and enhancing patient care outcomes through collaborative problem-solving.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Obtain more details of the client's claim of abuse. This is the most appropriate initial action because it prioritizes the client's safety and well-being. By gathering more information about the alleged abuse, the nurse can assess the situation comprehensively before taking further steps. Option A, focusing on reality orientation, is not the most immediate concern when a client discloses abuse. While it is important in certain situations, addressing the abuse claim takes precedence. Option B, assisting with the report to the police, should come after verifying the client's claim to ensure accuracy and appropriateness of involving law enforcement. Option D, documenting the statement on the client's chart, is important but should follow a thorough assessment and investigation of the abuse allegation to ensure proper documentation. Educationally, this question highlights the critical thinking skills needed in nursing practice when faced with sensitive and potentially harmful situations. It emphasizes the importance of assessing and investigating before taking action to ensure the best possible outcome for the client.