A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

Correct Answer: B

Rationale: The correct answer is B: Report of headache and stiff neck. This finding suggests a potential complication of epidural anesthesia called a post-dural puncture headache, which can indicate leakage of cerebrospinal fluid. This requires immediate intervention to prevent serious complications like meningitis or seizures. Redness at the catheter insertion site is common and typically resolves with proper care. A slight elevation in temperature (C) may not be urgent unless it's accompanied by other symptoms. Pain rating of 8 (D) is important but not as urgent as potential neurological complications.

Correct Answer: B

Rationale: The correct answer is B because paranoid delusions, neologisms, and echolalia are all considered positive symptoms of schizophrenia. Positive symptoms are behaviors or experiences that are added to a person's normal functioning, such as hallucinations, delusions, or disorganized speech. In this case, paranoid delusions involve false beliefs of being persecuted or harmed, neologisms refer to made-up words, and echolalia is the repetition of words or phrases spoken by others. Flat affect, anhedonia, and anergia are actually negative symptoms of schizophrenia. Negative symptoms involve deficits in normal functioning, such as a lack of emotional expression (flat affect), inability to experience pleasure (anhedonia), and lack of energy or motivation (anergia). Therefore, choice B correctly differentiates the client's positive and negative symptoms of schizophrenia.

Correct Answer: B

Rationale: The correct answer is B because stress can affect individuals unpredictably, making it essential to assess each client's stress levels. This allows for tailored interventions to address their unique stressors. Choice A is incorrect as stress levels vary among individuals. Choice C is incorrect because not all clients develop maladaptive coping strategies. Choice D is incorrect as the increase in mental illness prevalence does not directly correlate with the need for stress reduction interventions.

Correct Answer: B

Rationale: The correct answer is B: Perceived loss. The student is experiencing a perceived loss because she believes she is not smart enough to become a nurse based on one exam grade. This type of loss is based on the student's perception or belief rather than an actual loss of a tangible item or ability. It is a subjective interpretation of the situation, leading to feelings of inadequacy. A: Actual loss refers to a tangible loss of something concrete, which is not the case here. C: Physical loss pertains to the loss of a physical object or ability, which is not applicable in this situation. D: Situational loss involves a loss due to a specific situation or event, but in this case, the loss is more about the student's perception of her ability rather than a situational factor.

Correct Answer: C

Rationale: The correct answer, C, demonstrates awareness of safe, proficient nursing practice because it focuses on assessing the appropriateness of the medication and dose for the patient. This step ensures patient safety by verifying that the medication is suitable for the individual's condition and that the dosage is correct. It involves critical thinking and clinical judgment, aligning with the principles of patient-centered care and medication safety. Choices A and D are important steps in medication administration but do not directly address the crucial aspect of assessing the appropriateness of the medication for the patient. Checking the medication cart (A) ensures availability but does not guarantee suitability. Identifying the patient (D) is essential for patient safety but does not evaluate the medication itself. Choice B, checking the dose with another nurse, is a valuable safety measure to prevent medication errors but does not address the broader aspect of assessing the overall appropriateness of the medication for the specific patient's needs.