A woman in active labor is diagnosed with an obstetric emergency requiring immediate delivery. What is the priority nursing action?

Correct Answer: B

Rationale: In the situation of an obstetric emergency requiring immediate delivery, the priority nursing action is to prepare the delivery room for the birth. This involves ensuring that all necessary supplies and equipment are readily available, the bed is adjusted to the appropriate position, and the healthcare team is prepared to assist with the birth. By expeditiously preparing the delivery room, the healthcare team can facilitate a safe and timely delivery for both the mother and the baby. Notifications to the healthcare provider, administering intravenous fluids, and continuous fetal monitoring can be done simultaneously but preparing the delivery room takes precedence to ensure a prompt response to the emergent situation.

Correct Answer: A

Rationale: The response indicating Annie's present condition would be option A. This is because the symptoms mentioned in option A, such as experiencing vertigo, nausea, and nystagmus when sitting, point towards a vestibular disorder. These are symptoms commonly associated with conditions like Meniere's disease or vestibular neuritis, which can cause balance issues and feelings of dizziness. These symptoms are more indicative of Annie's current health status compared to the other options which focus on past or unrelated issues, such as ear pain during travel or impaired hearing since birth. The information provided in option A gives a more direct insight into Annie's present condition, making it the most appropriate response.

Correct Answer: C

Rationale: In this situation, the most appropriate response for the palliative nurse is to validate the patient's feelings of guilt and offer support to address their concerns. It is important to acknowledge the patient's emotions and help them navigate through their guilt in a compassionate and understanding manner. By validating their feelings, the nurse can create a safe space for the patient to express their concerns and work towards finding solutions to alleviate their guilt. This approach fosters trust and a therapeutic relationship between the patient and the nurse, ultimately promoting emotional well-being and facilitating open communication.

Correct Answer: A

Rationale: ** In a patient with ARDS, the priority intervention to manage respiratory failure is to initiate lung-protective mechanical ventilation with low tidal volume. ARDS is characterized by widespread inflammation and injury to the alveoli, leading to impaired gas exchange and severe hypoxemia. Lung-protective ventilation strategies aim to minimize ventilator-induced lung injury by using lower tidal volumes (around 6 mL/kg of predicted body weight) to reduce barotrauma and volutrauma.

Correct Answer: C

Rationale: False imprisonment is the act of improperly restraining another individual against their will. In this scenario, the nurse's threat of putting the client into seclusion and administering an injection to restrain them for inappropriate behavior constitutes false imprisonment. The client is being restricted in their movement without valid reason or proper procedure. This type of action is not acceptable in healthcare settings and violates the client's rights. It is important for healthcare professionals to use appropriate de-escalation techniques and interventions to manage challenging behaviors without resorting to threats of physical restraint.

Correct Answer: B

Rationale: Guillain-Barré Syndrome (GBS) is characterized by ascending motor weakness, starting typically in the lower extremities and progressing upwards. Patients with GBS often verbalize the early onset of symptoms as weakness starting in the legs and potentially spreading to involve the arms and sometimes the face. Therefore, the common verbalization of the patient with GBS regarding the early onset of symptoms is ascending motor weakness. Acute hemiplegia (choice A) and acute hemiparesis (choice D) involve weakness or paralysis typically limited to one side of the body, which is not a characteristic presentation of GBS. Weakness of the four lower extremities (choice C) is also not a typical description in GBS as the weakness usually starts distally and progresses proximally.

Correct Answer: C

Rationale: Mastitis is an infection of the breast tissue that may occur in postpartum clients. When a postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth, it is crucial to notify the healthcare provider immediately. Prompt medical evaluation is necessary to determine the appropriate treatment plan, which may include antibiotics. Delay in treatment can lead to complications, such as abscess formation. Encouraging the client to continue breastfeeding and applying warm compresses may provide some relief but do not address the underlying infection. Administering oral antibiotics would require a prescription from the healthcare provider, hence notifying the provider is the most appropriate initial nursing action in this situation.

Correct Answer: A

Rationale: Acanthosis nigricans is a skin condition characterized by multiple, hyperpigmented, velvety plaques typically seen in flexural areas such as the axillae, neck, and groin. These lesions are often associated with obesity and insulin resistance. The appearance of acanthosis nigricans is distinct from other skin conditions such as seborrheic keratosis, dermatofibroma, and epidermal nevus. Acanthosis nigricans is commonly seen in conditions like obesity, type 2 diabetes, and metabolic syndrome due to the insulin resistance that leads to the overgrowth of keratinocytes.

Correct Answer: C

Rationale: Verbal abuse is the most common form of abuse experienced by nurses in their workplace. This may include insults, yelling, threats, or intimidation directed towards the nurse. Verbal abuse can have a significant impact on the nurse's mental and emotional well-being, leading to stress, anxiety, and burnout. It is important for healthcare institutions to address and prevent verbal abuse to create a safe and respectful work environment for nurses and other healthcare professionals.