In planning for Sonny's oxygen therapy, the nurse should consider which of the following, EXCEPT

Correct Answer: C

Rationale: The nurse does not need to determine the age of Excel when planning for Sonny's oxygen therapy. This information is irrelevant to the specific care requirements of Sonny's oxygen therapy. Sonny's age, medical history, respiratory status, and oxygen needs are the key considerations in planning for his oxygen therapy. The nurse should focus on factors such as the need for a humidifier, length of tubing, and the manner of administering oxygen (continuous or intermittent) to ensure effective and safe delivery of oxygen therapy to Sonny.

Correct Answer: A

Rationale: Nurse Nilda likely opted to review Erikson's psychosocial theory because completion of each developmental task in the theory results in a sense of competence and contributes to the development of a healthy personality. Erikson's theory outlines different stages of psychosocial development that individuals go through, with each stage presenting a specific conflict or challenge to be resolved. Successfully navigating and resolving these challenges at each stage leads to the development of essential strengths and virtues. For example, in Erikson's stage of industry versus inferiority (ages 6 to 11 years), successfully completing tasks related to school, sports, and social interactions can lead to a sense of competence and accomplishment. Conversely, failure to master these tasks can lead to feelings of inadequacy and inferiority. By understanding and applying Erikson's theory, Nurse Nilda can better support individuals in their development and help promote positive outcomes.

Correct Answer: A

Rationale: Myxedema is a severe form of hypothyroidism that is characterized by the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues. This condition leads to puffiness, swelling, and thickening of the skin, giving it a waxy appearance. Other symptoms of myxedema include fatigue, weight gain, cold intolerance, and hair loss. It is important to recognize and treat myxedema promptly as it can lead to serious complications such as myxedema coma, which is a life-threatening condition requiring immediate medical attention.

Correct Answer: D

Rationale: Tipping Claudia's head back slightly helps in reaching the conjunctival sac easily. The conjunctival sac is a small space between the lower eyelid and the eye itself where eye drops are typically administered. Tilting the head back allows for better access to this area, ensuring the eye drops are delivered accurately and effectively into the eye.

Correct Answer: C

Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.