A patient with renal failure presents with confusion, seizures, asterixis, and a sweet odor to the breath. Laboratory findings reveal severe metabolic acidosis, hyperkalemia, and elevated blood urea nitrogen (BUN) and creatinine levels. What is the most likely diagnosis?

Correct Answer: B

Rationale: The patient's presentation with renal failure, confusion, seizures, asterixis, and a sweet odor to the breath, along with laboratory findings of severe metabolic acidosis, hyperkalemia, and elevated BUN and creatinine levels, is consistent with uremic encephalopathy. Uremic encephalopathy is a neurological complication of acute or chronic renal failure resulting from the buildup of uremic toxins in the blood, leading to various neurological symptoms such as confusion and seizures. The sweet odor to the breath can be attributed to the presence of urea, a waste product that accumulates in renal failure. Other metabolic abnormalities like hyperkalemia and severe metabolic acidosis are also common in renal failure. It is crucial to promptly recognize and manage uremic encephalopathy to prevent further neurological complications.

Correct Answer: B

Rationale: Spondylosis is a condition characterized by degenerative changes in the intervertebral discs, leading to narrowing of the disc space and the formation of osteophytes (bone spurs). This degenerative process commonly occurs with aging and can cause symptoms such as neck or back pain, stiffness, and reduced range of motion. Spondylosis is a common finding on imaging studies like X-rays and MRI scans in individuals over the age of 50 and is a natural part of the aging process of the spine.

Correct Answer: A

Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.

Correct Answer: A

Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.

Correct Answer: A

Rationale: Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is an increasing pulse and decreasing blood pressure. Hypovolemia is a condition where there is a decreased volume of circulating blood in the body, often characterized by fluid loss such as through bleeding. As blood volume decreases, the heart rate increases in an attempt to maintain adequate perfusion to organs and tissues. This results in an elevated pulse rate. Additionally, as the blood volume decreases, the blood pressure may drop due to the reduced amount of blood being pumped around the body. Therefore, monitoring for an increasing pulse and decreasing blood pressure is crucial in detecting hypovolemia early, allowing for prompt intervention to prevent further complications.

Correct Answer: C

Rationale: If the nurse notices that the patient's arms are not adequately padded while positioning for surgery, the nurse should immediately take action to prevent pressure injuries. Applying soft padding to the patient's arms will help distribute the pressure more evenly, reducing the risk of skin breakdown and potential harm to the patient during the surgical procedure. It is essential to prioritize the patient's safety and comfort in such situations. Simply proceeding with the positioning as planned could lead to complications, so addressing the inadequate padding promptly is the appropriate course of action.

Correct Answer: C

Rationale: Conducting a year-end performance evaluation of the staff is an example of a controlling function in management. Controlling involves monitoring and evaluating the performance of employees to ensure that they are working effectively and meeting the set goals and standards. By assessing the staff's performance at the end of the year, managers can identify areas of improvement, provide feedback, and make necessary adjustments to ensure the overall success of the organization. Hence, the process of evaluating staff performance falls under the controlling function of management.

Correct Answer: B

Rationale: The patient who had a left total hip replacement surgery due to osteoarthritis needs to strictly follow the postoperative teaching of being shown how to gently irrigate the external auditory canal because this instruction is unrelated to a hip replacement surgery. The other options are not relevant to the surgery and patient's condition. Option A about airplane travel, Option C about dizziness, and Option D about hair washing are not appropriate instructions for a patient who had a hip replacement. It is important for healthcare providers to give accurate and relevant postoperative instructions to help the patient recover successfully.

Correct Answer: D

Rationale: Since Nadine is just four years old, determining her favorite toys is not a critical aspect for Nurse Alma to consider in terms of routines and rituals. While knowing Nadine's favorite toys may help provide comfort or distraction, it is not as essential as ensuring proper feeding, sleep patterns, and toilet training for a young child's well-being and development. The focus should primarily be on aspects that directly impact her physical health, growth, and daily routines at this age.