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: A

Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.

Correct Answer: A

Rationale: The most appropriate intervention for the palliative nurse to prioritize in this situation is to arrange for family members or loved ones to be present at the patient's bedside. Having loved ones nearby can provide emotional support, comfort, and reassurance to the patient during their final moments. This can help alleviate the fear and anxiety the patient is experiencing about dying alone. Additionally, it can contribute to a sense of connectedness and peace for both the patient and their loved ones during this challenging time. Offering practical solutions to address the patient's emotional needs is key in providing holistic palliative care.

Correct Answer: B

Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.

Correct Answer: C

Rationale: Osteoarthritis in the hip joint can lead to weakness or dysfunction in the hip abductor muscles, causing a Trendelenburg gait. This gait abnormality is characterized by a dropping of the pelvis on the opposite side of the affected hip during weight-bearing on the affected leg. It is a common clinical manifestation of hip osteoarthritis due to the muscle weakness and altered mechanics in the hip joint. Baker's cyst is associated with knee osteoarthritis, Heberden's nodes are commonly seen in osteoarthritis of the fingers, and Swan-neck deformity is typically seen in rheumatoid arthritis, not osteoarthritis.

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: Guava leaves are recommended by the Department of Health as a remedy for cough due to their natural expectorant properties. The leaves contain compounds that help to loosen mucus and make it easier to expel, providing relief from cough and congestion. Guava leaves are commonly used in traditional medicine for respiratory conditions such as cough, bronchitis, and asthma. They help soothe the throat, reduce inflammation, and promote overall respiratory health. It is important to note that while guava leaves can be a helpful remedy for cough, they should be used in conjunction with other treatments as advised by healthcare professionals for best results.

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: Regular exercise is beneficial for individuals with diabetes, including your grandmother, because it helps increase metabolic rate and the consumption of glucose by the muscles. When someone exercises regularly, their muscles become more sensitive to insulin, which helps to lower blood sugar levels. This increased glucose utilization by the muscles can lead to better blood sugar control and overall improved management of diabetes. By incorporating regular exercise into her routine, your grandmother can potentially reduce the need for medications, maintain a healthier weight, and lower the risk of complications associated with diabetes.