In planning their care Nurse Gina should consider _______.

Correct Answer: B

Rationale: In planning their care, Nurse Gina should consider holistic care, which emphasizes treating the patient as a whole person - including their physical, mental, emotional, and spiritual needs. By addressing all aspects of the patient's well-being, Nurse Gina can provide comprehensive care that promotes overall health and wellness. This approach recognizes that physical health is interconnected with other aspects of a person's life and aims to support the individual in achieving balance and harmony in all areas. Holistic care also encourages the patient to be actively involved in their own healing process, fostering a sense of empowerment and self-awareness.

Correct Answer: A

Rationale: Neonatal Opioid Withdrawal Syndrome (NOWS), previously known as Neonatal Abstinence Syndrome (NAS), can occur when a newborn is exposed to opioids in utero. Opioid exposure in utero can lead to physical dependence in the fetus, and when the drug is no longer available after birth, withdrawal symptoms can occur.

Correct Answer: B

Rationale: Cardiogenic shock is a life-threatening condition where the heart is unable to pump enough blood to meet the body's demands. Monitoring the patient's cardiac index, which is a measure of cardiac output adjusted for body surface area, can help detect the risk of developing cardiogenic shock. A decrease in cardiac index would indicate a decrease in the heart's ability to effectively pump blood, putting the patient at risk for cardiogenic shock. Monitoring cardiac index is essential in assessing cardiac function and guiding interventions to prevent the progression to cardiogenic shock. The other factors listed may provide important information in assessing the patient's condition, but specifically in detecting the risk of developing cardiogenic shock, monitoring the cardiac index is crucial.

Correct Answer: C

Rationale: The most appropriate intervention for a patient with end-stage dementia experiencing agitation and restlessness is to create a calm and soothing environment to promote relaxation. Patients with dementia often respond positively to a familiar and tranquil setting, which can help reduce their symptoms of agitation and restlessness. This approach is preferred over administering antipsychotic medications or recommending physical exercise, as these may not be feasible or beneficial for patients in the advanced stages of dementia. Referring the patient to a psychiatrist may not address the immediate need for symptom management and can be considered if other interventions are ineffective. Creating a calm environment, such as dim lighting, soft music, and familiar objects, can help provide comfort and reduce distress for the patient.

Correct Answer: A

Rationale: The nurse should prioritize adjusting the irrigation flow rate based on the patient's urine output to prevent complications during continuous bladder irrigation (CBI). Proper adjustment of the irrigation flow rate helps maintain adequate bladder drainage while preventing bladder distention, clot formation, and potential irrigation fluid overload. Monitoring the patient's urine output and adjusting the flow rate accordingly ensures optimal functioning of the CBI system and enhances patient safety. This proactive approach minimizes the risk of complications and promotes effective postoperative care following urological surgery.

Correct Answer: C

Rationale: Feedback is an essential indicator of effective communication because it allows the sender to understand how the message was received by the receiver. It provides an opportunity to clarify any misunderstandings, confirm understanding, and ensure that the communication has been successful. Without feedback, the sender cannot be sure if their message was accurately understood or if further explanation or clarification is needed. Effective communication involves a two-way exchange, and feedback plays a crucial role in ensuring that the message is effectively transmitted and received.

Correct Answer: B

Rationale: When managing a conscious patient with a severe nosebleed (epistaxis), the appropriate intervention is to have the patient sit upright and lean slightly forward to prevent blood from flowing into the throat and causing choking or swallowing. Pinching the soft part of the nose just below the bony part can help apply pressure to the bleeding vessel and stop the bleeding. This maneuver also helps compress the blood vessels in the nose, promoting clot formation and stopping the bleeding. It is important not to tilt the head back as this can cause blood to flow into the throat and potentially lead to swallowing, choking, or aspiration. Packing the nose with cotton gauze should be done by medical professionals if the bleeding does not stop with direct pressure. Applying direct pressure to the forehead is not effective for managing nosebleeds; pressure should be applied to the nostrils instead.

Correct Answer: D

Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.

Correct Answer: C

Rationale: In clients with ALS (Amyotrophic Lateral Sclerosis), death typically occurs within two to three years of diagnosis. This is often due to progressive weakness and degeneration of the muscles involved in breathing, leading to respiratory failure. As the disease advances, the muscles responsible for breathing become increasingly compromised, eventually resulting in the inability to breathe effectively without mechanical ventilation support. Other complications such as aspiration pneumonia and malnutrition may also contribute to the decline in health. Therefore, respiratory failure is the primary cause of death in clients with ALS.