During a blood transfusion, which observation indicates that the client is experiencing a transfusion reaction?

Correct Answer: D

Rationale: Complaints of back pain and shortness of breath are classic signs of a transfusion reaction, specifically indicating a hemolytic reaction. This reaction can lead to the release of hemoglobin into the bloodstream, causing back pain and shortness of breath due to clot formation in the blood vessels, leading to decreased oxygen delivery. Warmth, flushing, rash, chills, and fever are more commonly associated with allergic reactions or febrile non-hemolytic reactions during transfusions. Therefore, options A, B, and C are incorrect in this context.

Correct Answer: C

Rationale: The statement 'I can't find my missing shoes. Have you seen them?' displays disorganized thinking or speech, which is characteristic of a thought disorder. The mention of 'missing shoes' in a context that does not make logical sense suggests a disturbance in thought processes. Choices A, B, and D do not demonstrate disorganized thinking typical of thought disorders. Option A reflects emotional expression, option B indicates mild confusion, and option D shows a redirection of focus to someone else's problem.

Correct Answer: D

Rationale: The correct answer is D because maturational loss is related to developmental changes, such as children leaving for college. This type of loss is tied to the normal life transitions of individuals and can lead to feelings of grief and adjustment. Choices A, B, and C represent different types of losses. Choice A involves a traumatic loss of a child due to illness, choice B involves a financial loss impacting the head of household's job, and choice C involves a material loss due to a fire incident. While these losses are significant, they do not specifically relate to maturational loss, which is associated with expected life stage transitions.

Correct Answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

Correct Answer: A

Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.

Correct Answer: C

Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.

Correct Answer: C

Rationale: A full urine collection bag can cause the device to pull away from the skin, leading to potential leakage and skin irritation. Choice A is incorrect because a full urine collection bag does not force urine to back up into the kidneys. Choice B is incorrect as a full collection bag does not suppress the production of urine. Choice D is incorrect as a full collection bag is unlikely to tear the ileal conduit.

Correct Answer: A

Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare. Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment. Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record. Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.

Correct Answer: A

Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.