A patient with advanced dementia is no longer able to communicate verbally and displays signs of distress. What should the palliative nurse consider when assessing and managing the patient's distress?

Correct Answer: C

Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.

Correct Answer: B

Rationale: When a patient is unable to talk, the nurse can best communicate with the patient by using picture cards. Picture cards can help the patient convey their needs, feelings, or responses by pointing to the corresponding pictures. This method allows for effective communication and understanding between the patient and the nurse, even when verbal communication is not possible. It promotes patient autonomy and ensures that their needs are accurately communicated and addressed. Additionally, picture cards can be a useful tool in reducing frustration and anxiety for patients who are unable to communicate verbally.

Correct Answer: A

Rationale: In delegation, facilitating the professional growth and development of a staff is necessary because it allows team members to gain new skills and experience, leading to overall improved productivity and job satisfaction. This empowers staff and helps them feel more engaged in their work, ultimately benefiting the entire unit. Effective delegation should aim to support individuals in their roles, encourage learning, and build competence, rather than modifying standards of care or only delegating tasks without considering individual growth. Starting delegation from top management to staff-nurse level may not always be practical or efficient, as delegation should be based on competencies and responsibilities. Accountability is indeed a crucial aspect of delegation, as individuals should be held responsible for the tasks they are delegated. However, without providing opportunities for professional growth and development, delegation may not be as effective in achieving organizational goals.

Correct Answer: B

Rationale: The nurse's best approach to address the patient's fear of pain is to provide accurate information about pain management strategies and options. In doing so, the nurse can help alleviate the patient's concerns by empowering them with knowledge and potential solutions for managing pain during and after the procedure. By acknowledging the patient's fear and addressing it with practical information, the nurse can build trust, reduce anxiety, and create a more supportive and collaborative environment for the patient. Dismissing, ignoring, or invalidating the patient's fear would not be effective in addressing the underlying concerns and could potentially lead to increased distress and resistance to the recommended procedure.

Correct Answer: C

Rationale: The last and necessary part of any activity should involve an evaluation process. By evaluating the activity, the organizers can gather feedback on what worked well and what areas need improvement. This feedback is crucial for enhancing future activities that are similar in nature. It allows for reflections on the effectiveness of the activity, identifies strengths and weaknesses, and helps in making necessary adjustments for better outcomes in the future. Overall, evaluation ensures continuous improvement and development in organizing successful activities.

Correct Answer: C

Rationale: In the emergency department setting, the initial diagnostic test typically performed for a patient suspected of having a stroke is a noncontrast computed tomography (CT) scan of the head. This imaging study is crucial in evaluating and diagnosing stroke because it can quickly identify whether the person is having a hemorrhagic stroke (bleeding in the brain) or an ischemic stroke (blood clot blocking a blood vessel). The results of the CT scan help guide immediate treatment decisions, such as administering clot-busting medications for ischemic strokes or preparing for surgical interventions for hemorrhagic strokes. Carotid ultrasound studies and transcranial Doppler flow studies may be performed after the initial CT scan to further assess the extent of damage and the underlying cause of the stroke. The 12-lead electrocardiogram is useful in assessing the heart's electrical activity but is not the primary test for diagnosing stroke.

Correct Answer: A

Rationale: In the case of a woman in active labor with placenta previa, the priority nursing intervention is to prepare for an immediate cesarean section. Placenta previa is a condition in which the placenta covers part or all of the cervix, which can lead to severe bleeding during labor and delivery. The risk of hemorrhage is significant, making a cesarean section the safest option for both the mother and the baby in this situation. It is crucial to act promptly to prevent complications and ensure the well-being of both the mother and the baby. Administering intravenous oxytocin to augment labor or inserting a Foley catheter to monitor urine output would not address the immediate risk of hemorrhage associated with placenta previa. Implementing bed rest and continuous fetal monitoring may be part of the overall care plan but not the priority intervention in this urgent situation.

Correct Answer: A

Rationale: Clients who are taught skills such as measuring blood glucose, taking blood pressure, changing dressings, and bathing infants are learning skills that involve physical movement and coordination. These activities require the integration of mental and physical skills, and they fall under the psychomotor domain of learning. In this domain, individuals develop physical skills and coordination through practice and repetition. The psychomotor domain is one of the three domains of learning, along with the cognitive domain (which involves knowledge and intellectual skills) and the affective domain (which involves emotions, values, and attitudes).

Correct Answer: C

Rationale: The presentation described with a sensation of fullness and pressure in the left ear, along with hearing loss and occasional tinnitus, and the findings of a retracted tympanic membrane with decreased mobility on pneumatic otoscopy are most consistent with serous otitis media, also known as otitis media with effusion (OME). OME is characterized by the presence of non-infected fluid in the middle ear space, leading to symptoms such as ear fullness, hearing loss, and occasionally tinnitus.