Correct Answer: A

Rationale: In the scenario described, the patient was considered an emergency case upon referral to the tertiary hospital. Since a specialist was immediately called for by the nurse, the most likely specialist needed in an emergency situation is a neurologist. Neurologists are physicians who specialize in diagnosing and treating disorders of the nervous system, including the brain, spinal cord, and nerves. In an emergency case where a patient's neurological condition needs urgent attention, a neurologist would be the most appropriate specialist to address the situation promptly and effectively.

Correct Answer: C

Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.

Correct Answer: B

Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.

Correct Answer: B

Rationale: Negligence refers to the failure to act or perform duties according to the standard of care expected from a reasonable person in similar circumstances. In this case, Nurse Lina administering a penicillin injection that was ordered for another patient is a clear instance of negligence. It involves a breach of duty by not verifying the correct patient and medication before administration. While malpractice can also encompass negligence, it typically involves a broader scope of professional misconduct or harm caused by a healthcare provider. Assault and battery involve intentional harmful acts, which are not applicable in this situation.

Correct Answer: B

Rationale: Nursing interventions should be aimed at addressing the mother's needs for psychological security. Hyper vigilance and excessive worry about her child's safety indicate a lack of security in her mind. By providing support, reassurance, and education, nurses can help the mother feel more secure in her role as a parent and reduce her feelings of anxiety and distress. Establishing trust and building a therapeutic relationship can also contribute to enhancing the mother's psychological security and well-being.