A postpartum client who delivered via cesarean section expresses concerns about breastfeeding positions and comfort. What nursing intervention should be prioritized to address the client's concerns?

Correct Answer: A

Rationale: Demonstrating breastfeeding positions that minimize pressure on the incision site should be the nursing intervention prioritized to address the client's concerns. This is important because it ensures that the client can breastfeed comfortably while also protecting the healing incision. By showing the client appropriate positions, such as the football hold or side-lying position, the nurse can help minimize discomfort and promote successful breastfeeding without compromising the cesarean incision's healing process. It is crucial to support the client in establishing a good latch and positioning to encourage proper milk transfer and bonding while being mindful of the incision site.

Correct Answer: D

Rationale: The correct answer is D: Breastfeeding. HIV transmission from mother to infant can occur through breast milk due to the presence of the virus in breast milk. Other choices such as A: Bathing, B: Bottlefeeding, and C: Washing of vagina do not involve direct contact with potentially infected body fluids like breast milk, making them less likely to transmit the virus. Breastfeeding is a well-documented mode of HIV transmission from mother to infant, hence it is the correct choice in this scenario.

Correct Answer: D

Rationale: The correct immediate action for the nurse is to notify the anesthesia provider immediately (Option D). This is crucial because a sudden change in the patient's level of consciousness during surgery could indicate a serious issue related to anesthesia administration. Notifying the anesthesia provider promptly allows for quick assessment and intervention to address the underlying cause, potentially preventing complications or even saving the patient's life. Administering a reversal agent (Option A) without proper evaluation by the anesthesia provider could be dangerous. Documenting the change in the patient's chart (Option B) is important but not the most immediate action. Checking the patient's vital signs (Option C) is also important but may not provide immediate insight into the cause of the change in consciousness.

Correct Answer: A

Rationale: The correct answer is A: Implement environmental modifications to promote sleep hygiene. Delirium is often triggered by environmental factors like noise, light, and disruption of sleep. By optimizing the environment for rest and minimizing stimuli, the patient's delirium can improve. This approach focuses on addressing the root cause rather than just managing symptoms. Choice B is incorrect because antipsychotic medications can worsen delirium and are not recommended as first-line treatment. Choice C is not the priority as ruling out focal deficits may be important but does not directly address the delirium. Choice D is incorrect as benzodiazepines can exacerbate delirium and are not recommended due to their potential to worsen cognitive function.

Correct Answer: D

Rationale: The correct answer is D: Subarachnoid hemorrhage. This condition presents with sudden-onset severe headache, vomiting, and altered mental status due to bleeding in the subarachnoid space. This type of hemorrhage is typically noncontrast-enhancing on imaging. A: Ischemic stroke does not typically present with sudden-onset severe headache and vomiting. B: Subdural hematoma usually presents with a slower onset of symptoms and often develops after head trauma. C: Intracerebral hemorrhage presents with focal neurological deficits rather than altered mental status and vomiting. In summary, based on the sudden onset of symptoms, imaging findings, and clinical presentation, subarachnoid hemorrhage is the most likely diagnosis in this case.

Correct Answer: C

Rationale: The correct answer is C: Anaphylaxis. Anaphylaxis is the MOST severe form of an allergic reaction, including latex allergy. It is a systemic, potentially life-threatening reaction that can involve multiple organ systems. Symptoms can include difficulty breathing, swelling of the throat, a rapid drop in blood pressure, and cardiovascular collapse. Pruritus, erythema, and swelling (choice A) are common symptoms of allergic reactions but not specific to anaphylaxis. Asthma (choice B) can be a manifestation of latex allergy but is not the most severe form. Blisters and other skin lesions (choice D) are not typical of anaphylaxis but can occur in some cases of contact dermatitis from latex exposure.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Confirming the patient's identity ensures the right patient is receiving the intended procedure. 2. Verifying the procedure site using two identifiers prevents errors in site selection. 3. This step aligns with the World Health Organization's Surgical Safety Checklist, reducing the risk of wrong-site procedures. 4. Positioning, sedation, and local anesthesia are important but secondary to ensuring the correct patient and site. Summary: - Option B: Positioning is essential but not the top priority for procedural accuracy. - Option C: Sedation aims to minimize discomfort but does not guarantee procedural accuracy. - Option D: Administering local anesthesia is crucial but not as critical as confirming patient identity and procedure site.

Correct Answer: D

Rationale: The correct answer is D because informed consent should be obtained from both the participants and their parents to ensure full understanding and agreement from all parties involved. This is crucial when working with minors to protect their rights and ensure ethical standards are met. Choice A is incorrect as it excludes parental consent, which is necessary for minors. Choice B is also incorrect as it neglects the participants' direct involvement in consenting to participate. Choice C is incorrect because it only includes available relatives, which may not be legally authorized to provide consent on behalf of the participants.

Correct Answer: A

Rationale: Correct Answer: A: To help control the intra-ocular pressure Rationale: 1. Eye surgery can lead to increased intra-ocular pressure. 2. Instilling eye drops can help reduce this pressure post-surgery. 3. Controlling intra-ocular pressure is crucial for proper healing and preventing complications. 4. Eye drops for infection (B) or pupil dilation/constriction (C, D) are not primary concerns post-eye surgery.