A postpartum client with a history of breast augmentation expresses concerns about breastfeeding difficulties. What nursing intervention should be prioritized to support successful breastfeeding in this situation?

Correct Answer: D

Rationale: Referring the client to a lactation consultant for specialized support should be prioritized to support successful breastfeeding in this situation. Breast augmentation surgery may impact milk production, let-down reflex, and proper latch due to alterations in breast tissue and nerve pathways. A lactation consultant can provide individualized guidance and support to address these specific challenges. Additionally, the consultant can assist in establishing a breastfeeding plan tailored to the client's unique needs, helping to optimize the breastfeeding experience for both the mother and the baby. It is crucial to seek expert assistance in navigating any potential difficulties that may arise from breastfeeding after breast augmentation to promote successful breastfeeding outcomes.

Correct Answer: C

Rationale: Autonomy is the ethical principle that upholds an individual's right to make decisions about their own medical treatment, free from coercion or undue influence. In this scenario, the 70-year-old patient has voluntarily decided not to have the pacemaker inserted despite the physician's recommendation. The fact that the decision is respected by the family further highlights the importance of autonomy in this situation. Respecting the patient's right to make choices regarding their own healthcare, even if it goes against medical advice, demonstrates a commitment to autonomy as an ethical principle.

Correct Answer: A

Rationale: The best thing to do next is to turn off the fan immediately. The fact that the electric fan is stopping every now and then and sparking at intervals indicates a potential electrical issue or malfunction. This situation poses a safety hazard as it increases the risk of an electrical fire or damage to the fan. Turning off the fan immediately will help prevent any further damage or potential danger. After turning off the fan, it would be advisable to call for maintenance to inspect and repair the fan to ensure it is safe to use again.

Correct Answer: B

Rationale: The most appropriate action for the nurse to take when noticing that the patient seems anxious and is avoiding eye contact is to ask the patient if they are feeling anxious and if they would like to talk about it. This approach shows empathy, concern, and openness to addressing the patient's emotional state. By directly acknowledging the patient's behavior and giving them the opportunity to express their feelings, the nurse can create a supportive and caring environment that promotes effective communication and trust between the patient and healthcare provider. It is important to consider the patient's emotional well-being alongside their physical health during consultations.

Correct Answer: A

Rationale: The FIRST action of the nurse should be to reassess the client experiencing dyspnea despite continuous oxygen therapy. Reassessment would involve checking the client's respiratory status, oxygen saturation levels, vital signs, and overall condition to gather more information about the situation. This will help the nurse identify any potential causes of the dyspnea and determine the appropriate next steps for intervention. Assessing the client before proceeding with any other actions is crucial in providing safe and effective care.

Correct Answer: D

Rationale: The purpose of record keeping in healthcare is primarily to ensure quality health care. Maintaining accurate and up-to-date records of patient information, including medical history, treatments, medications, and test results, allows healthcare providers to make informed decisions about patient care. Access to complete and organized records helps in providing timely and effective treatments, reducing errors, and ensuring continuity of care. By tracking and documenting patient care, healthcare professionals can assess outcomes, monitor progress, and improve overall quality of healthcare services. Additionally, thorough record keeping also supports communication between healthcare providers and facilitates coordination of care across different healthcare settings.

Correct Answer: C

Rationale: In a conscious trauma patient with a suspected head injury, maintaining cervical spine immobilization is crucial. The presence of a head injury raises concerns for potential concomitant cervical spine injury. Therefore, it is vital to prevent any movement of the cervical spine to avoid exacerbating a potential spinal cord injury. Maintaining immobilization involves stabilizing the patient's head and neck in a neutral position until appropriate imaging studies can assess the extent of any spinal injury. This action helps prevent further harm and ensures the safety of the patient during assessment and management of their injuries.

Correct Answer: A

Rationale: Acute pyelonephritis is the most likely condition based on the patient presentation and urinalysis findings described. Acute pyelonephritis is an infection of the renal parenchyma and pelvis, typically caused by ascending bacteria from the lower urinary tract. The classic symptoms include fever, chills, flank pain, and costovertebral angle tenderness (tenderness over the kidneys). The presence of pyuria (pus in the urine) and bacteriuria (bacteria in the urine) on urinalysis further supports the diagnosis of acute pyelonephritis. It is crucial to diagnose and treat acute pyelonephritis promptly to prevent complications and recurrent infections.

Correct Answer: C

Rationale: According to Erikson's theory of psychosocial development, the stage of Identity versus Role Confusion occurs during adolescence, which is typically around the ages of 12 to 18 years old. This stage is characterized by the individual exploring and developing their personal identity, values, and beliefs.