It is important that Nurse Chona records accurately the restless caused by pain and that of hypoxia. Which of the following should be recorded as the restlessness caused by pain?

Correct Answer: D

Rationale: Restlessness caused by pain often manifests as increased perspiration and constant change of position. When a person is in pain, they may become sweaty or clammy due to increased sympathetic nervous system activity. Additionally, they may constantly shift or fidget in an attempt to find a more comfortable position that can alleviate the pain they are experiencing. Therefore, it is crucial for Nurse Chona to accurately document these behaviors as signs of pain-related restlessness. Difficulty of breathing (Option A), increased respiratory rate and blood pressure (Option B), and increased heart rate (Option C) are more indicative of hypoxia or respiratory distress rather than pain-related restlessness.

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: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.

Correct Answer: D

Rationale: The bio-ethical principle of veracity pertains to honesty and truthfulness in healthcare communication. By providing fraudulent information about the patient's diagnosis and prognosis, the nurse would be violating the principle of veracity. It is crucial for healthcare providers to be honest and provide accurate information to patients in order to ensure informed decision-making and uphold the trust between healthcare professionals and their patients. Misleading a patient about their diagnosis and prognosis can have serious consequences on the patient's understanding of their condition, treatment decisions, and overall well-being. Therefore, maintaining honesty and truthfulness is essential in promoting ethical healthcare practices.

Correct Answer: B

Rationale: In order to understand and interpret a message accurately, it is essential to consider the context in which it was delivered. Context provides the necessary background information, setting, and circumstances that give meaning and relevance to the message being communicated. Without context, it can be challenging to fully grasp the intention and significance of the communication. While the other options (process, phrases and sentences, thoughts and feelings) play roles in communication, it is the context that ultimately helps to give meaning and context to the message being conveyed.

Correct Answer: C

Rationale: Humoral immunity is primarily responsible for protecting against infections by pathogens like viruses. In the case of the hepatitis B virus (HBV), the individual is exposed to the virus and develops immunity, which is typically mediated by antibodies produced by B cells. These antibodies circulate in the blood and can neutralize the virus, preventing future infections. This type of immunity is known as humoral immunity, as it involves the production of antibodies that target specific antigens, such as those present on the surface of the hepatitis B virus. In contrast, passive immunity is when antibodies are transferred from an external source, innate immunity provides immediate, non-specific defenses against pathogens, and cell-mediated immunity involves the activation of T cells to combat intracellular pathogens.

Correct Answer: C

Rationale: The patient's presentation of excessive thirst, frequent urination, and fatigue align with the classic symptoms of diabetes mellitus. The laboratory findings of hypernatremia (high sodium levels), hyperglycemia (high blood sugar levels), and metabolic acidosis further support this diagnosis. In diabetes mellitus, the body is unable to properly regulate blood sugar levels due to either insufficient insulin production (Type 1 diabetes) or ineffective use of insulin by the cells (Type 2 diabetes). This leads to high blood sugar levels, causing symptoms such as polyuria (frequent urination), polydipsia (excessive thirst), and fatigue. The metabolic acidosis is a result of the body's breakdown of fats and proteins for energy due to the lack of glucose utilization in the cells.

Correct Answer: D

Rationale: Nurse Parker functioned independently when she initiated the visit by arranging for the clergy to see patient Ximena. In this scenario, the nurse took the initiative on her own without needing approval or direction from others. She recognized the patient's request for spiritual guidance and took independent action to meet that need. Independently functioning in this context demonstrates the nurse's autonomy and ability to make decisions based on the patient's preferences and well-being.

Correct Answer: B

Rationale: Option B is the most appropriate response when addressing a postpartum client's concerns about resuming sexual activity after a vaginal delivery. Educating the client about the normal changes in sexual desire and response following childbirth can help alleviate anxiety and provide reassurance. It is crucial for the nurse to explain that it is common for women to experience changes in libido, physical discomfort, and emotional adjustments after giving birth. By discussing these normal postpartum changes, the nurse can support the client in understanding that her feelings are valid and that it may take time for her to feel ready to engage in sexual activity again. Furthermore, the nurse can provide information on ways to enhance comfort and intimacy when resuming sexual activity, such as communication with partners, using lubricants, and gradually easing back into sexual activity as desired.