A patient admitted to the ICU develops severe sepsis with refractory hypotension despite adequate fluid resuscitation. What intervention should the healthcare team prioritize to manage the patient's septic shock?

Correct Answer: A

Rationale: In the scenario described, the patient is experiencing refractory hypotension despite adequate fluid resuscitation, indicating the presence of septic shock. In septic shock, systemic vasodilation and vascular hyporesponsiveness contribute to hypotension. Therefore, the primary management approach is to restore vascular tone and blood pressure to maintain organ perfusion. Administering vasopressor medications (Choice A) is the crucial intervention to achieve this goal. Vasopressors, such as norepinephrine or vasopressin, constrict blood vessels and increase blood pressure, helping to stabilize the patient in septic shock. While options B and C (performing blood cultures and initiating broad-spectrum antibiotics) are important for identifying the causative pathogen and treating the infection, they are secondary to the immediate need for hemodynamic support in septic shock. Prophylactic anticoagulation (Choice D) is not the primary intervention for

Correct Answer: C

Rationale: The described presentation of a yellowish-white spot on the cornea with a ring of inflammation, along with branching, filamentous opacities extending from the corneal lesion, is characteristic of fungal keratitis. Fungal keratitis typically presents with these specific features on clinical examination.

Correct Answer: A

Rationale: Providing emotional support and empathy for the client's experience should be prioritized to address concerns of a postpartum client who experienced a traumatic birth. Emotional support can help the client feel validated and heard, which can be instrumental in starting the healing process. By acknowledging the client's emotions and experiences, the nurse can establish trust and create a safe space for the client to express their feelings. This can also help in building a therapeutic relationship that can positively impact the client's emotional well-being. Providing a supportive environment is essential for addressing breastfeeding difficulties and emotional distress in this situation.

Correct Answer: B

Rationale: Battery in the context of healthcare refers to the intentional and unauthorized touching of a patient. By applying a body restraint without a doctor's order, Nurse Edna has potentially committed battery against the patient. It is important for healthcare providers to obtain proper authorization before implementing any physical restraints on a patient to avoid legal liabilities such as battery.

Correct Answer: D

Rationale: False imprisonment occurs when a client is physically restrained or confined without legal justification. In this scenario, the nurse restraining the confused and combative client without a physician's order constitutes false imprisonment. Restraints should only be used when necessary to ensure the safety of the client or others, and a physician's order is required to authorize their use. In this case, the nurse acted without proper authorization, making it a violation of the client's rights and false imprisonment. It is essential to follow proper protocols and obtain necessary orders before restraining a client.

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: B

Rationale: In Stage I of Hodgkin's disease, the most commonly seen early symptom is usually unexplained fever and night sweats. Other common symptoms at this stage may include unexplained weight loss, itching, and enlarged lymph nodes in the neck, underarms, or groin. Chest and back pains, subnormal body temperature, and swelling of extremities are not typically early indicators of Stage I Hodgkin's disease.

Correct Answer: C

Rationale: Toddlers are typically children who are 1 to 3 years old. In this context, the toddlers are children in the age range of 9 to 36 months old. This period is marked by significant cognitive, emotional, and social development as children in this age group start to explore their environments, develop their language skills, begin to understand emotions, and interact with others. It is a crucial stage in a child's development where they start becoming more independent and forming their own identities.

Correct Answer: C

Rationale: Lamotrigine (Lamictal) is known to cause a serious rash, such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which can be life-threatening. Therefore, it is crucial for patients taking Lamotrigine to be aware of this potential side effect and report any skin rashes to their healthcare provider promptly. Early detection and appropriate management are essential in preventing serious complications related to these rashes.