Nurse Sandy selected a framework which focuses " that humans are in constant relationship with stressors in the environment and that nursing is keeping the patient's system adjust to wellness which is BEST reflected in _______.

Correct Answer: C

Rationale: Neuman's adaptation model, also known as the Neuman Systems Model, is a nursing theory that focuses on how individuals respond to stressors in their environment. The model views individuals as being in a constant state of dynamic equilibrium, where they are interacting with stressors that can disrupt their normal functioning. Nursing care, according to this model, is aimed at helping individuals maintain or restore their optimal level of wellness by assisting them in adapting to these stressors. Therefore, Nurse Sandy's selection of a framework that emphasizes the constant relationship between humans and stressors in the environment aligns best with Neuman's adaptation model.

Correct Answer: C

Rationale: Mastitis is an infection of the breast tissue that may occur in postpartum clients. When a postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth, it is crucial to notify the healthcare provider immediately. Prompt medical evaluation is necessary to determine the appropriate treatment plan, which may include antibiotics. Delay in treatment can lead to complications, such as abscess formation. Encouraging the client to continue breastfeeding and applying warm compresses may provide some relief but do not address the underlying infection. Administering oral antibiotics would require a prescription from the healthcare provider, hence notifying the provider is the most appropriate initial nursing action in this situation.

Correct Answer: C

Rationale: Maintaining patient confidentiality is a foundational principle in healthcare ethics. Nurses are obligated to keep all information about patients confidential, which means not disclosing any patient-related information to unauthorized individuals. This includes refraining from discussing patient cases with others who are not directly involved in the care of the patient. Sharing patient information without consent can be a breach of trust and privacy, which can have legal and ethical implications. Therefore, in order to uphold the principle of confidentiality, nurses must keep all matters about the patient as a secret.

Correct Answer: A

Rationale: A strong team is cohesive, meaning its members work well together, communicate effectively, and support each other. Cohesion helps the team to function smoothly and achieve its goals efficiently. While being driven, having shared goals, and a sense of mission are important characteristics of a strong team, cohesion is the foundation that holds the team together and allows these other factors to thrive.

Correct Answer: C

Rationale: The night nurse is expected to collect the patient charts from various departments every three nights. Among the tasks listed, binding the charts as they are is not typically a responsibility of the night nurse. This task is usually handled by administrative staff or professional medical records technicians who are trained to manage the organization and storage of patient charts. The night nurse's primary focus should be on ensuring the correct order of the charts, checking for completeness, and addressing any issues such as torn pages by taping or repairing them to maintain the integrity of the patient records.

Correct Answer: C

Rationale: Progesterone in oral contraceptives works primarily by inhibiting ovulation. It suppresses the secretion of luteinizing hormone (LH) from the pituitary gland, which is essential for triggering the release of an egg (ovulation) from the ovary. By blocking ovulation, progesterone helps prevent pregnancy by making it less likely for a mature egg to be available for fertilization. This mechanism of action is a key factor in the effectiveness of progesterone-containing contraceptives in preventing pregnancy.

Correct Answer: D

Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.

Correct Answer: D

Rationale: All of the components -explanation of the procedure and alternatives to the procedure (I), discussion of potential risks and benefits of the procedure (II), and confirmation that the patient understands the risks, benefits, and any alterations (III) -are essential parts of informed consent. Providing information about the procedure and its alternatives, disclosing potential risks and benefits, and ensuring that the patient comprehends this information are crucial to obtaining valid informed consent prior to any medical procedure.

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.