A patient with advanced heart failure expresses fear and anxiety about the progression of their illness. What is the palliative nurse's most appropriate response?

Correct Answer: C

Rationale: The palliative nurse's most appropriate response in this scenario is to offer empathetic listening and explore the patient's concerns about the future. By providing a compassionate and supportive environment for the patient to express their fears and anxieties, the nurse can help the patient feel heard and understood. This approach allows the nurse to address the patient's emotional needs and provide appropriate support to help them cope with their feelings. Avoiding discussions or minimizing the patient's concerns may invalidate their emotions and hinder the therapeutic relationship. Encouraging distraction techniques or focusing solely on positive thoughts may not address the underlying fears and anxieties that the patient is experiencing. Therefore, offering empathetic listening and exploring the patient's concerns is the most appropriate way for the nurse to provide holistic care for the patient with advanced heart failure.

Correct Answer: B

Rationale: Opsonization is a process in the immune response where opsonins, which are proteins such as antibodies and complement proteins, bind to pathogens such as bacteria, making them more easily recognized and engulfed by phagocytic cells like macrophages and neutrophils. This coating of pathogens by opsonins enhances the efficiency of phagocytosis, helping in the elimination of pathogens from the body. Opsonins do not facilitate cell lysis, neutralize toxins, or stimulate histamine release; their main function is to tag pathogens for phagocytosis.

Correct Answer: D

Rationale: When administering Rilutek (riluzole), the medication should be taken with food. This is because taking Rilutek with food helps to reduce the likelihood of experiencing stomach upset as a side effect. Administering the medication on an empty stomach may increase the risk of gastrointestinal issues such as nausea, vomiting, or stomach pain. Therefore, it is recommended to administer Rilutek with food to ensure better tolerability for the patient.

Correct Answer: A

Rationale: Developing a routine with the patient to balance her studies and rest needs is the most appropriate intervention to promote rest. This approach considers the patient's responsibilities and can help her organize her time effectively to ensure she gets adequate rest while managing her studies. It acknowledges the importance of rest without completely disregarding the patient's other commitments, ultimately fostering a balanced approach to self-care. This intervention is patient-centered and collaborative, empowering the patient to take an active role in prioritizing rest alongside her educational responsibilities.

Correct Answer: D

Rationale: Confirming the patient's informed consent before the procedure is the most crucial action for the nurse to prioritize to ensure procedural safety during a thoracentesis. Informed consent is a legal and ethical requirement that ensures the patient understands the purpose of the procedure, its potential risks, benefits, and alternatives. By confirming informed consent, the nurse ensures that the patient has the necessary information and has willingly agreed to undergo the procedure. This process promotes patient autonomy, prevents misunderstandings, and reduces the likelihood of legal issues related to the procedure. Additionally, verifying informed consent helps establish a foundation of trust between the healthcare team and the patient. While other actions like positioning the patient correctly and ensuring pre-procedure antibiotics may also contribute to the safety of the procedure, obtaining informed consent is the foundational step that must be prioritized.

Correct Answer: C

Rationale: The practice of advocacy in nursing involves assessing the client's point of view and preparing to articulate this viewpoint. Advocacy requires that nurses actively listen to their patients, understand their perspectives, and ensure that their needs and wishes are communicated effectively within the healthcare team. By advocating for the client's point of view, nurses can help empower their patients to make informed decisions about their care and ensure that their best interests are always prioritized.

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: D

Rationale: Involution refers to the process of the uterus returning to its nonpregnant state after childbirth. During pregnancy, the uterus undergoes significant changes and enlarges to accommodate the growing fetus. After childbirth, the uterus begins to contract, leading to a decrease in its size and a return to its pre-pregnant state. This process involves the shedding of the excess endometrial tissue and the reduction of the size of the uterine muscle fibers. It is a normal and essential process for postpartum recovery. Failure of the uterus to undergo proper involution is known as subinvolution, which can lead to complications such as postpartum hemorrhage.

Correct Answer: B

Rationale: The laboratory test used to monitor the therapeutic effect of warfarin therapy is the International Normalized Ratio (INR). Warfarin is a commonly prescribed anticoagulant medication that works by inhibiting the action of vitamin K-dependent clotting factors. Maintaining the INR within the target range specific to the indication for anticoagulation (e.g., DVT prevention or treatment) is essential to balance the risk of bleeding and clotting.