A nurse is caring for a patient who is experiencing end-of-life symptoms. What action by the nurse demonstrates palliative care principles?

Correct Answer: C

Rationale: Providing emotional support and addressing psychosocial needs demonstrates palliative care principles when caring for a patient experiencing end-of-life symptoms. Palliative care focuses on holistic care that encompasses physical, emotional, and spiritual support for patients and their families during times of serious illness. By addressing emotional needs and providing support, the nurse helps improve the patient's quality of life and comfort during this difficult time. This approach goes beyond just managing physical symptoms and pain, recognizing the importance of supporting the patient's overall well-being. Encouraging the patient to make decisions about life-sustaining treatments is also an important aspect of palliative care, but providing emotional support and addressing psychosocial needs is crucial in palliative care practice.

Correct Answer: D

Rationale: The engagement of the fetus refers to the baby's head moving down into the mother's pelvis in preparation for birth. This factor is not typically used to distinguish between true and false labor because it is a sign of progress in labor rather than a defining characteristic of true labor. In contrast, the factors that are commonly used to differentiate between true and false labor include contractions (e.g., regularity, intensity, duration), cervical changes observed through vaginal examination (e.g., effacement and dilation), and monitoring vital signs.

Correct Answer: D

Rationale: Non-maleficence is the ethical principle that emphasizes the obligation to avoid causing harm to patients. In this scenario, the ER nurse clarifies the doctor's prescription to ensure the correct dosage of the pain medication based on the pain scale assessment and the patient's age. By doing so, the nurse is ensuring that the medication is safe and effective for the patient, thus adhering to the principle of non-maleficence. This action demonstrates the nurse's commitment to preventing harm and promoting the well-being of the patient through proper medication management.

Correct Answer: C

Rationale: The presentation of persistent, severe headache, visual disturbances, and epigastric pain in a postpartum client could indicate the development of postpartum preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Prompt notification of the healthcare provider is essential to ensure timely assessment, diagnosis, and treatment to prevent potential complications for both the mother and baby. Encouraging rest, providing acetaminophen, or offering a massage are not appropriate interventions for addressing these symptoms, as they do not address the underlying cause and urgency of the situation.

Correct Answer: C

Rationale: Assessing the patient's airway is the first priority when admitting injured patients. A clear airway is crucial for effective breathing. If the airway is obstructed, the patient will not be able to breathe properly, leading to serious consequences. Therefore, ensuring a patent airway takes precedence over assessing breathing, circulation, or vital signs. Once the airway is secured, the emergency team can proceed with assessing breathing, circulation, and vital signs in order to provide appropriate treatment and care.

Correct Answer: B

Rationale: When a patient is diagnosed with pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would typically include fine crackles. Fine crackles are discontinuous, high-pitched crackling or rattling sounds heard during inspiration that indicate the presence of fluid in the small airways or alveoli. These crackles are caused by the movement of secretions or exudate within the bronchioles or alveoli, which is a common characteristic of pneumonia. Wheezing sounds are usually associated with conditions such as asthma, bronchitis, or COPD and are caused by narrowed airways. Stridor is a high-pitched, crowing sound that typically indicates an obstruction in the upper airway and is often heard in cases of laryngeal inflammation or foreign body aspiration. Deep and low-pitched breath sounds are more characteristic of conditions like chronic bronchitis.

Correct Answer: D

Rationale: The nurse's actions exemplify negligence. Negligence is a failure to provide reasonable care that results in harm to a patient. In this scenario, the nurse failed to unclamp the patient's indwelling urinary catheter as instructed by the healthcare provider. This failure to follow proper procedure led to the patient developing a urinary tract infection, which could have been prevented if the nurse had acted with reasonable care. This action does not meet the criteria for malpractice, assault, or battery as those involve intentional harm or professional misconduct, whereas negligence involves a lack of appropriate care or attention.

Correct Answer: C

Rationale: Nurse Cora should consider statement C as TRUE with anorexia nervosa. Cultures that portray thinness as the ideal standard of beauty can increase the risk of developing anorexia nervosa. This is because individuals may internalize these societal norms and feel pressure to attain the thin ideal, leading to disordered eating behaviors.

Correct Answer: A

Rationale: Maternal dehydration can contribute to a prolonged latent phase during labor. Dehydration can lead to reduced blood volume and electrolyte imbalances, which can result in ineffective uterine contractions. Without adequate hydration, the uterus may not contract effectively, causing irregular and infrequent contractions. It is important for the nurse to assess the woman's hydration status and encourage her to stay hydrated during labor to help regulate contractions and progress labor.