Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply?

Correct Answer: C

Rationale: The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Epinephrine. When a client goes into cardiac arrest, the body initiates the stress response known as the fight-or-flight response. Epinephrine, also known as adrenaline, is a hormone released by the adrenal glands in response to stress. It plays a crucial role in increasing heart rate, constricting blood vessels, and dilating air passages to increase oxygen delivery to the body's tissues during emergencies like cardiac arrest. Option A) Endorphin is incorrect because endorphins are the body's natural painkillers and are not typically secreted in large amounts during a sudden cardiac arrest. Option B) Endothelin is incorrect as it is a peptide that constricts blood vessels, but it is not the primary hormone secreted in response to cardiac arrest. Option D) Erythropoietin is incorrect as it is a hormone primarily involved in the production of red blood cells and the regulation of blood oxygen levels, not in the immediate response to cardiac arrest. In an educational context, understanding the body's response to stress and emergencies like cardiac arrest is crucial for healthcare providers, especially nurses working in emergency settings. Knowing the role of hormones like epinephrine can help nurses anticipate and respond effectively to critical situations, ultimately improving patient outcomes.

Correct Answer: A

Rationale: In the context of grief and loss, a person's first response is often denial (or shock). This initial reaction serves as a defense mechanism to protect the individual from the overwhelming emotions associated with the loss. Denial allows the person to gradually come to terms with the reality of the situation at a pace that they can handle, providing a buffer against the intense pain of the loss. Anger, bargaining, and depression are also common responses to grief, but they typically follow the initial stage of denial. Anger may arise as the individual struggles to make sense of the loss, while bargaining involves seeking ways to reverse or mitigate the circumstances leading to the loss. Depression often sets in as the person starts to fully grasp the magnitude of their loss and the impact it will have on their life. Educationally, understanding the stages of grief and loss can help individuals, including healthcare providers, support clients and patients experiencing these emotions. By recognizing and validating these responses, professionals can offer appropriate support and interventions to help individuals navigate through their grief process in a healthy and constructive manner. It is essential to acknowledge and respect each individual's unique journey through grief, recognizing that there is no one-size-fits-all approach to coping with loss.

Correct Answer: B

Rationale: In understanding medication absorption, it is crucial for nurses to grasp the differences in absorption rates based on administration routes. The correct answer, B) Intravenous (IV) injection, has the fastest absorption rate. This is because IV administration delivers the medication directly into the bloodstream, bypassing the need for absorption through tissues or the gastrointestinal tract. As a result, the medication can reach its target site more rapidly, leading to a quicker onset of action. Option A) Cream applied to the skin, and Option C) Enteric-coated (EC) capsules, both have slower absorption rates compared to IV injections. Cream applied to the skin must first penetrate the skin barrier and then be absorbed into the bloodstream, which can be a relatively slow process. Enteric-coated capsules are designed to dissolve in the intestines rather than the stomach, delaying absorption. Option D) Subcutaneous (SC) injection also has a slower absorption rate than IV injections. While SC injections are absorbed more quickly than oral medications, they are still not as rapid as IV administration due to the difference in blood supply and tissue characteristics. Educationally, understanding the absorption rates of different medication administration routes is vital for nurses to ensure the timely and effective delivery of medications to patients. This knowledge can impact treatment outcomes, especially in critical situations where rapid drug action is necessary for patient safety and well-being.

Correct Answer: C

Rationale: In the context of client safety and home monitoring, the nurse should recommend the client to use the radial pulse site. The radial pulse is easily accessible at the wrist, making it convenient for the client to monitor regularly at home. It is also a common site used in healthcare settings for assessing pulse rate and rhythm. Educating clients to monitor their radial pulse can empower them to actively participate in their own healthcare and detect any abnormalities early. Regarding the other options: - Apical pulse is located at the apex of the heart and is commonly used for accurate assessment of heart rate but is not practical for routine home monitoring. - Pedal pulse is located on the foot and is not commonly used for routine pulse monitoring, especially at home. - Femoral pulse is located in the groin area and is not easily accessible for self-monitoring, making it impractical for home use. By understanding the rationale behind recommending the radial pulse site, clients can take charge of their health by monitoring their pulse effectively and promptly reporting any concerns to their healthcare provider. This empowers clients to actively participate in their own care and promotes client safety and well-being.