Nurse Juvy's assessment reveals the following: Heart Rate is 110 beats per minute, has a vigorous cry, moves actively and with good flexion, normal skin color and bluish extremities. What would be thd APGAR score of Baby Sharon?

Correct Answer: B

Rationale: Baby Sharon's APGAR score can be determined by assessing five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criteria is given a score of 0, 1, or 2 points, with 2 being the highest score.

Correct Answer: B

Rationale: The nurse's role in interdisciplinary collaboration is crucial for providing comprehensive and effective patient care. By actively participating in healthcare team meetings, the nurse should listen attentively to the input of other team members, contribute their expertise, and share relevant information about the patient's condition. Collaboration involves working together towards shared goals, pooling knowledge and resources, and fostering mutual respect among team members. The nurse's active involvement in the care planning process helps ensure coordinated and patient-centered care delivery. This approach enhances communication, improves outcomes, and promotes a holistic approach to patient care.

Correct Answer: C

Rationale: When a postpartum client exhibits signs of wound infection, such as erythema, warmth, and purulent drainage from a cesarean incision, it is essential to notify the healthcare provider immediately. Wound infections can lead to serious complications if not promptly addressed. The healthcare provider will assess the infection, possibly order further diagnostic tests, and determine the appropriate course of treatment, which may include antibiotics or additional wound care measures. Applying a dressing or irrigating the wound may be part of the treatment plan prescribed by the healthcare provider, but the first step is always to seek guidance from the provider.

Correct Answer: A

Rationale: The clinical presentation of fever, chills, headache, and myalgia following a trip to sub-Saharan Africa is highly suggestive of malaria, which is caused by the Plasmodium species. Specifically, the presence of intraerythrocytic ring forms and trophozoites on blood smear examination points towards Plasmodium falciparum as the most likely causative agent.

Correct Answer: C

Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.

Correct Answer: D

Rationale: In cases where a patient becomes seriously ill or is harmed due to receiving the wrong medication, both the nurse and the hospital are likely to be held liable. The nurse is responsible for administering the correct medication to the patient, and any error in this process can lead to harm. The hospital may also be held liable for the actions of its employees, including nurses, under the legal principle of vicarious liability. Additionally, the hospital has a duty to ensure that proper protocols are in place to prevent medication errors, and failure to do so can lead to liability. Therefore, in this scenario, both the nurse and the hospital are likely to share liability for the patient's harm.

Correct Answer: B

Rationale: Clozapine is an atypical antipsychotic medication primarily used in the treatment of schizophrenia. One of the positive effects of Clozapine is the reduction of psychotic symptoms experienced by the patient, such as hallucinations (not hearing loss). Clozapine is effective in managing both positive symptoms (hallucinations, delusions, disorganized thinking) and negative symptoms (apathy, social withdrawal, lack of motivation) of schizophrenia. It is known for its efficacy in reducing hallucinations and other psychotic symptoms, helping the patient to lead a more stable and functional life.

Correct Answer: D

Rationale: Advocacy is the ethical principle that the nurse is responsible for providing all patients with caring attention and information, despite the reaction of the patient. Advocacy involves supporting and speaking up for the patient's best interests, ensuring they receive the care and information they need to make informed decisions about their health and well-being. Providing caring attention and information is essential in advocating for the patient's autonomy and well-being, even if the patient may not initially appreciate or react positively to these efforts.

Correct Answer: A

Rationale: Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness. Individuals with ADHD may have difficulty paying attention, completing tasks, sitting still, or controlling their impulses. Mental retardation (now referred to as intellectual disability) is a separate condition characterized by limitations in intellectual functioning and adaptive behaviors. While individuals with ADHD may experience difficulties in school or work due to their symptoms, ADHD itself does not indicate mental retardation.