A patient is prescribed a tricyclic antidepressant for the management of depression. Which adverse effect should the nurse monitor closely in the patient?

Correct Answer: A

Rationale: Tricyclic antidepressants (TCAs) are known to have anticholinergic effects, which can lead to various cardiovascular side effects, including orthostatic hypotension, tachycardia, and potential hypertension. While hypotension is a possible adverse effect, hypertension is more commonly associated with TCAs. Therefore, it is essential for the nurse to monitor the patient for signs of hypertension, such as elevated blood pressure readings, to prevent any adverse outcomes and ensure the patient's safety while on this medication.

Correct Answer: D

Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.

Correct Answer: C

Rationale: In this situation, the most appropriate response for the palliative nurse is to validate the patient's feelings of guilt and offer support to address their concerns. It is important to acknowledge the patient's emotions and help them navigate through their guilt in a compassionate and understanding manner. By validating their feelings, the nurse can create a safe space for the patient to express their concerns and work towards finding solutions to alleviate their guilt. This approach fosters trust and a therapeutic relationship between the patient and the nurse, ultimately promoting emotional well-being and facilitating open communication.

Correct Answer: A

Rationale: Rheumatoid arthritis is a common cause of secondary osteoporosis. Chronic inflammation in rheumatoid arthritis can lead to bone loss due to increased osteoclast activity and decreased bone formation. Patients with rheumatoid arthritis are at an increased risk for developing osteoporosis, resulting in decreased bone density and increased fracture risk. Monitoring and managing bone health is an important aspect of care for individuals with rheumatoid arthritis to help prevent osteoporosis-related complications.

Correct Answer: B

Rationale: The extraneous variable in a study is a variable that is not the main focus of the study but could potentially impact the results. In this case, the length of stay is an extraneous variable because it is not directly related to the research question or objective of the study. The study is likely focused on factors such as patient age, complications, or date of admission, making the length of stay an irrelevant variable in this context.

Correct Answer: D

Rationale: Restlessness caused by pain often manifests as increased perspiration and constant change of position. When a person is in pain, they may become sweaty or clammy due to increased sympathetic nervous system activity. Additionally, they may constantly shift or fidget in an attempt to find a more comfortable position that can alleviate the pain they are experiencing. Therefore, it is crucial for Nurse Chona to accurately document these behaviors as signs of pain-related restlessness. Difficulty of breathing (Option A), increased respiratory rate and blood pressure (Option B), and increased heart rate (Option C) are more indicative of hypoxia or respiratory distress rather than pain-related restlessness.

Correct Answer: B

Rationale: The effects of AIDS on pregnancy do not generally include repeated abortion as a direct consequence. AIDS can impact pregnancy by increasing the risk of complications such as premature birth, low birth weight, and potential transmission of the virus from mother to child. Infertility can also be a concern, but repeated abortion is not a common effect of AIDS on pregnancy. It is important to provide accurate information about the effects of AIDS on pregnancy to ensure proper understanding and support for individuals affected by this condition.

Correct Answer: D

Rationale: Complete abortion is the most likely cause of the symptoms described. In a complete abortion, all products of conception are expelled from the uterus. Symptoms include vaginal bleeding, passage of tissue, and dilation of the cervix. In this scenario, the presentation of a dilated cervix with visualized products of conception is classic for a complete abortion at 10 weeks gestation.

Correct Answer: A

Rationale: Reporting observed signs of child abuse to the Department of Social Welfare Development (DSWD) is the best nursing action in cases of suspected child abuse. DSWD is the government agency tasked with protecting the welfare of children and families. They have the necessary authority and resources to investigate and intervene in cases of child abuse. Reporting to DSWD ensures that professional social workers and experts will step in to assess the situation, provide necessary interventions, and ensure the safety of the child. It is important to involve the appropriate authorities who are trained to handle cases of child abuse effectively. Reporting to the DSWD helps in safeguarding the well-being of the child and taking the necessary steps to address the situation appropriately.