It is not enough for the nurse to listen, but she also has, to validate what she has heard. The importance of validation are the following EXCEPT _____

Correct Answer: B

Rationale: The importance of validation in the context of communication and nursing care does not include the assumption that most patients are cognitively impaired. It would be more appropriate to approach patient interactions with the assumption that patients are capable of understanding and coherent communication. Validation is important because it helps ensure that the nurse has truly understood the patient's message, prevents misinterpretation, and fosters a sense of empathy and trust in the nurse-patient relationship. Additionally, validating the patient's thoughts and feelings can help clarify confused thoughts and promote effective communication. The other options (A, C, and D) are all valid reasons emphasizing the significance of validation in effective communication.

Correct Answer: C

Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.

Correct Answer: C

Rationale: Cryptosporidium parvum is a protozoan parasite that commonly causes waterborne illness characterized by watery diarrhea, abdominal cramps, and nausea. This parasite is often transmitted through contaminated water sources such as streams or lakes. Laboratory tests identifying oocysts in the stool sample are indicative of Cryptosporidium infection. Giardia lamblia can also cause similar symptoms, but the presence of oocysts points more towards Cryptosporidium in this case. Entamoeba histolytica causes amoebic dysentery with bloody diarrhea and is usually associated with fecal-oral transmission through contaminated food or water. Cyclospora cayetanensis typically causes prolonged watery diarrhea and is associated with the ingestion of contaminated food or water.

Correct Answer: A

Rationale: Turning and repositioning the patient every 2 hours is the most effective nursing intervention in preventing pressure ulcers in a patient with a history of stroke and immobility. Pressure ulcers, also known as bedsores, are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage. By regularly turning and repositioning the patient, pressure is relieved from specific areas of the body, helping to prevent the development of pressure ulcers. This intervention helps to redistribute pressure, improve blood flow, and reduce the risk of skin breakdown, thus promoting skin integrity in immobile patients.

Correct Answer: D

Rationale: Respect for persons is an ethical principle that emphasizes the autonomy and freedom of individuals to make their own decisions regarding participation in research studies. In the context of human subjects research, this principle requires that individuals have the right to choose whether or not to participate in a study, without any coercion or manipulation. The principle of respect for persons also includes the concept of informed consent, where individuals must be provided with all necessary information about the study in order to make an informed decision about participation. Overall, respecting the autonomy and choices of individuals is a fundamental aspect of ethical research conduct.

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: The presentation of sudden-onset unilateral facial droop, arm weakness, and slurred speech that partially resolved within 30 minutes is more consistent with a transient ischemic attack (TIA) rather than an ischemic or hemorrhagic stroke. TIAs are caused by temporary decreases in blood flow to a specific area of the brain, leading to transient neurological deficits that typically last for less than 24 hours. In this case, the symptoms partially resolving suggest a temporary and reversible ischemic event, characteristic of a TIA. Ischemic strokes involve more prolonged or permanent impairment due to blockage of a blood vessel supplying the brain, while hemorrhagic strokes involve bleeding within the brain tissue or the surrounding membranes.

Correct Answer: A

Rationale: The presentation of painless, progressive visual field loss, especially in the peripheral vision, along with an open iridocorneal angle is characteristic of open-angle glaucoma. Open-angle glaucoma is a type of glaucoma where there is no physical obstruction to the outflow of aqueous humor from the eye, but there is gradual damage to the optic nerve over time. The gradual loss of peripheral vision is a common early symptom of open-angle glaucoma. It is essential to diagnose and manage open-angle glaucoma promptly to prevent irreversible vision loss.

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.