A postpartum client presents with persistent, severe abdominal pain, tenderness, and rigidity. Which nursing action is most appropriate?

Correct Answer: C

Rationale: Persistent, severe abdominal pain, tenderness, and rigidity in a postpartum client can be indicative of serious conditions such as uterine rupture, hemorrhage, or infection, which require urgent medical attention. As a nurse, the priority action in this situation is to notify the healthcare provider immediately so that appropriate interventions can be initiated promptly to ensure the safety and well-being of the client. Administering analgesics or providing emotional support may not address the underlying cause of the symptoms and could potentially delay necessary medical treatment. Assisting the client to a comfortable position can be considered once the healthcare provider has been informed and appropriate assessments and interventions have been initiated.

Correct Answer: C

Rationale: When a pregnant woman is diagnosed with preeclampsia, the focus of health care shifts to the individual woman herself. Preeclampsia is a serious condition that affects the health of the pregnant woman and her unborn child. The healthcare team will prioritize the care and treatment of the woman to ensure her well-being and safety. In this scenario, the emphasis is on providing personalized and targeted care to address the needs of the individual patient, rather than a broader focus on population groups, communities, or families.

Correct Answer: A

Rationale: Pressure injuries on the heels are a concern as they can develop quickly and lead to serious complications, especially in surgical patients who are immobile for extended periods. Applying pressure-relieving devices, such as heel protectors or foam dressings, can help alleviate the pressure on the affected areas and prevent further damage. These devices are designed to distribute pressure evenly and reduce the risk of pressure injuries. It is important for the nurse to address the issue promptly to prevent additional harm to the patient's skin integrity.

Correct Answer: B

Rationale: Delegation by succession involves passing on responsibility and authority to a designated successor when the delegator is temporarily unavailable. In this scenario, the unit manager is planning to take her regular official business leave and has recommended her assistant unit manager to assume her position during her absence. This act follows the principle of succession, where the deputy or next in line is entrusted with the duties and decision-making power of the manager. This ensures a smooth transition of responsibilities and allows the operations to continue efficiently in the manager's absence.

Correct Answer: D

Rationale: In this scenario, the patient's presentation of a painless thyroid nodule and hoarseness of voice is consistent with papillary thyroid carcinoma, a type of thyroid cancer. While Hashimoto's thyroiditis and Graves' disease are autoimmune thyroid conditions that can lead to thyroid nodules, they typically do not present with hoarseness of voice. Diabetes mellitus does not directly cause these symptoms. Thyroid cancer, particularly papillary thyroid carcinoma, is the most likely cause based on the patient's clinical presentation and the biopsy results.

Correct Answer: A

Rationale: In this critical situation, the safety of the wife is of utmost importance. Whenever a healthcare provider becomes aware of a direct threat to someone's safety, especially related to potential harm or violence, it is their ethical and legal responsibility to report this information to the appropriate authorities promptly. In this case, the nurse should alert the proper authorities, such as law enforcement or a mental health crisis team, to ensure that immediate steps are taken to protect the wife from harm. Confidentiality should be breached in situations where there is a clear threat to an individual's safety. Keeping the information confidential in this scenario could result in serious harm or even loss of life. The nurse must act quickly to protect the potential victim.

Correct Answer: A

Rationale: The appropriate approach of the nurse in this situation would be to talk about the reality of death with the father. It is important to provide appropriate and compassionate communication, acknowledging the father's grief while also gently guiding him towards accepting the reality of the situation. By discussing the reality of death and offering support, the nurse can help the father start the grieving process and eventually come to terms with the loss of his son. It is important to provide emotional support and guidance in a sensitive and respectful manner during such a difficult time.

Correct Answer: A

Rationale: Acute Respiratory Distress Syndrome (ARDS) is a severe form of acute lung injury that is characterized by hypoxemia, bilateral pulmonary infiltrates, and noncardiogenic pulmonary edema. When managing a patient with ARDS in the ICU, the priority intervention is to provide adequate oxygenation and ventilation. Mechanical ventilation is often necessary to support gas exchange in these patients.

Correct Answer: D

Rationale: A patient with chronic kidney disease prescribed a low-protein diet should avoid high-protein foods like grilled salmon, lentil soup, and beef stew. Chicken Caesar salad, on the other hand, typically contains a smaller amount of protein compared to the other options. This choice indicates an understanding of the need to limit protein intake while still enjoying a balanced meal. However, it is important to note that the quantity and portion sizes of high-protein ingredients in the salad should also be moderate to comply with a low-protein diet.