Friendly but professional overtures have finally made Marlene open up her circumstances to the nurse, including their financial difficulty. What has been established at this time?

Correct Answer: B

Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.

Correct Answer: B

Rationale: When Nurse Sarah distributed a Patient satisfaction survey form to be filled by the consumer upon discharge in a hospital setting, it aligns with the quality standard of identifying Patient rights and welfare. Patient satisfaction surveys aim to gather feedback from patients about their experiences with the health care services provided. By distributing such surveys, the hospital is demonstrating its commitment to ensuring the rights and welfare of patients by seeking their feedback, understanding their concerns, and incorporating their suggestions for improvement. This initiative helps in enhancing the quality of care provided to patients and ultimately contributes to improving overall patient outcomes and satisfaction.

Correct Answer: B

Rationale: The correct information about the nature of dengue fever that the nurse should relay to the community is that it could be deadly but preventable. Dengue fever is a viral infection spread by mosquitoes, particularly the Aedes aegypti mosquito. While many cases of dengue fever are mild, it can also lead to severe dengue, which can be life-threatening if not properly managed. However, preventive measures such as using mosquito repellent, wearing protective clothing, and eliminating breeding sites for mosquitoes can significantly reduce the risk of contracting dengue fever. Therefore, it is important for the community to be aware that while dengue fever can be deadly, it is also preventable with appropriate measures.

Correct Answer: A

Rationale: Providing education on techniques to enhance milk production and supply should be prioritized to address the client's concerns about milk supply and meeting the baby's nutritional needs. By educating the client on proper breastfeeding techniques, frequent nursing sessions, skin-to-skin contact, and the importance of staying hydrated, the nurse can help promote successful breastfeeding and potentially increase milk production. Supplemental formula feedings are not the first line of intervention, as breastfeeding should be encouraged, especially for a preterm infant who may benefit significantly from breast milk. Encouraging the client to avoid breastfeeding until the infant reaches full term is not appropriate, as breastfeeding can still be beneficial for a preterm infant. Referring the client to a dietitian for specialized nutritional support may be beneficial, but addressing milk supply concerns through education should be prioritized initially to support breastfeeding success.

Correct Answer: C

Rationale: Providing oral rehydration with electrolyte solutions is the appropriate action for managing a conscious patient with suspected heat cramps. Heat cramps are muscle pains or spasms that often occur during intense exercise in hot environments when a person sweats excessively, losing both fluids and electrolytes. Replenishing lost fluids and electrolytes through oral rehydration helps address the underlying cause of the cramps and provides relief to the patient. Massaging the affected muscles vigorously can potentially worsen the condition, applying cold packs is not usually recommended for heat-related conditions, and encouraging the patient to continue strenuous activity can lead to further complications.

Correct Answer: C

Rationale: When caring for patients with hyperbilirubinemia, the nursing care plan should focus on informing the significant others, preventing injury, and preventing complications. The primary goal in managing hyperbilirubinemia is to prevent complications associated with high bilirubin levels, such as kernicterus. Therefore, maintaining physiological homeostasis with bilirubin levels increasing would not be appropriate and should not be the focus of the nursing care plan. It is crucial to monitor and manage bilirubin levels to prevent adverse outcomes rather than allowing them to increase.

Correct Answer: C

Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.

Correct Answer: C

Rationale: Type 2 diabetes mellitus is characterized by insulin resistance in the peripheral tissues and defective beta cell secretion with loss of insulin. In type 2 diabetes, there is typically not destruction of beta cells from an autoimmune mechanism that leads to lack of insulin and hyperglycemia as seen in type 1 diabetes mellitus. Instead, in type 2 diabetes, the pancreas initially produces insulin, but the body's cells become resistant to its effects. This results in hyperglycemia due to the inability of the body to properly regulate blood sugar levels. Therefore, choice C is not true for type 2 diabetes mellitus.

Correct Answer: B

Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.