A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take?

Correct Answer: B

Rationale: The correct answer is B: Move the probe site every 3 hours. This is important to prevent skin breakdown and ensure accurate readings. Moving the probe site helps to redistribute pressure and prevent tissue damage. Placing the infant under a radiant warmer (A) is not necessary for pulse oximetry monitoring. Heating the skin (C) can cause burns or discomfort. Placing the sensor on the index finger (D) may not provide accurate readings for an infant. Moving the probe site every 3 hours is the best practice to maintain skin integrity and ensure accurate monitoring.

Correct Answer: B

Rationale: The correct answer is B: Laboratory test results. Allostatic load refers to the cumulative wear and tear on the body as a result of chronic stress. Laboratory test results, such as cortisol levels, inflammation markers, and lipid profiles, provide direct indicators of physiological changes associated with stress. These results offer insights into how the body is responding to stress at a biochemical level. Explanation for why other choices are incorrect: A: Nuclear imaging studies - While nuclear imaging studies can provide valuable information about organ function, they are not typically used to directly measure the impact of stress on the body. C: Bone radiographs - Bone radiographs are used to assess bone structure and density, not typically associated with measuring allostatic load or stress-related changes. D: Cardiac studies - Cardiac studies focus on heart function and cardiovascular health, which can be influenced by stress but may not directly reflect the overall changes associated with allostatic load as comprehensively as laboratory test results.

Correct Answer: C

Rationale: The correct answer is C: mental illness. Severe anxiety that impacts daily functioning is indicative of a mental illness. Mental illnesses are conditions that affect a person's thinking, feeling, behavior, or mood. In this case, the client's inability to work due to increased anxiety indicates a significant impairment in their mental health. This falls within the category of mental illness on the continuum of mental health to mental wellness. Summary: A: Emotional problems or concerns typically refer to temporary issues such as stress or relationship difficulties, not as severe as a mental illness. B: Well-being signifies a positive state of overall health and happiness, which is not the case when a person is unable to function due to severe anxiety. D: Between well-being and emotional problems does not accurately capture the severity of the client's condition, which is indicative of a mental illness.

Correct Answer: B

Rationale: The correct answer is B: Antipsychotics. Nursing assessment for abnormal movement disorders is crucial for individuals taking antipsychotics due to the risk of developing extrapyramidal symptoms such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. These movement disorders can significantly impact the individual's quality of life and require close monitoring by healthcare providers. Summary: A: SSRIs - SSRIs are not typically associated with abnormal movement disorders; they are more commonly linked to serotonin-related side effects like sexual dysfunction or gastrointestinal disturbances. C: Benzodiazepines - Benzodiazepines are not known to cause abnormal movement disorders at therapeutic dosages; they are more likely to cause sedation, dizziness, and cognitive impairment. D: Tricyclic antidepressants - While tricyclic antidepressants can cause side effects like dizziness and sedation, they are not primarily associated with abnormal movement disorders like antipsychotics.

Correct Answer: D

Rationale: The correct answer is D (1.002). A urine specific gravity of 1.002 indicates very dilute urine, suggesting the client may be experiencing severe water imbalance, such as overhydration or excessive fluid intake. In contrast, choices A, B, and C represent more concentrated urine, which would typically be seen in conditions like dehydration or fluid retention. Therefore, D is the correct answer as it indicates a significant deviation from the normal range, signaling a severe water balance issue.

Correct Answer: A

Rationale: The correct answer is A because it highlights the key difference in a therapeutic nurse-patient relationship: the focus on the patient's needs and active participation in problem-solving. The nurse facilitates discussion but empowers the patient to make decisions and implement solutions, promoting autonomy and self-efficacy. Choice B is incorrect because it suggests a more equal exchange of advice and implementation of solutions, which can blur professional boundaries and hinder the patient's growth. Choice C is incorrect as it emphasizes socialization and meeting mutual needs, which are more characteristic of social relationships rather than therapeutic ones focused on the patient's mental health needs. Choice D is incorrect because it describes a partnership focused on mutual growth and satisfaction, which may not always align with the therapeutic goals of addressing the patient's mental health issues effectively.

Correct Answer: D

Rationale: The correct answer is D because sharing prescription medication, such as Norco, with others is illegal and dangerous. Step 1: Sharing opioids is illegal and can lead to legal consequences. Step 2: Sharing opioids can result in harmful drug interactions or overdose due to individual variations in tolerance and health conditions. Step 3: It is important to emphasize the importance of using prescribed medications only as directed by a healthcare provider for safety and effectiveness. Choices A, B, and C are incorrect because they are all appropriate self-management strategies for managing back pain in older adults with spinal stenosis.

Correct Answer: A

Rationale: The correct answer is A: Can be made aware of their delusions. Schizotypal personality disorder is characterized by odd behaviors and beliefs, but individuals with this disorder can maintain some awareness of their unusual thoughts. This is in contrast to schizophrenia, where individuals may have difficulty recognizing their delusions as false. Therefore, the ability to be made aware of their delusions sets schizotypal individuals apart from those with schizophrenia. Choices B, C, and D are incorrect: B: Are far more delusional than schizophrenics - This is incorrect as the severity of delusions can vary among individuals with different mental health disorders. C: Have a greater need for socialization - This is incorrect as schizotypal individuals often struggle with social interactions and may prefer solitude. D: Do not usually respond to antipsychotic medications - This is incorrect as individuals with schizotypal personality disorder may benefit from antipsychotic medications for symptom management.

Correct Answer: D

Rationale: The correct answer is D: De-escalation. Milieu therapy focuses on creating a therapeutic environment to promote healing and growth. De-escalation techniques are not a key concept of milieu therapy. Rationale: 1. Structure interaction (A): Correct - Milieu therapy emphasizes structured interactions between individuals to enhance communication and support. 2. Open communication (B): Correct - Milieu therapy encourages open and honest communication within the therapeutic environment. 3. Validation (C): Correct - Milieu therapy emphasizes validating individuals' feelings and experiences to promote a supportive environment. 4. De-escalation (D): Incorrect - De-escalation techniques are more commonly associated with crisis intervention and managing challenging behaviors, not a core concept of milieu therapy. In summary, de-escalation is not a key concept of milieu therapy, which focuses on promoting a therapeutic environment through structured interactions, open communication, and validation.