Signs such as using tissues to doorknobs develop because the patient is ________.

Correct Answer: A

Rationale: Signs such as using tissues to doorknobs suggest that the patient is unconsciously controlling unacceptable impulses or feelings. This behavior falls under the category of defense mechanisms, specifically displacement, where the individual redirects their emotions from a threatening target to a safer one. In this case, the patient may be experiencing anxiety or fear related to contamination or germs, leading them to use tissues to avoid touching doorknobs directly. It is a way for the patient to manage their underlying emotions, albeit unconsciously, through this compulsive behavior.

Correct Answer: D

Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.

Correct Answer: B

Rationale: Helping the family recognize the problem is the most appropriate intervention to assist them in performing health tasks. By recognizing the problem, the family can better understand the need for action and be motivated to take steps to address it. This intervention enables the family to become more engaged in their healthcare decision-making process and enhances their ability to effectively manage their health tasks. It empowers them to seek appropriate health resources and make informed choices in promoting their health and well-being. Ultimately, by acknowledging the problem, the family is better equipped to initiate positive changes and improve their overall health outcomes.

Correct Answer: D

Rationale: The BEST rationale for the conduct of the program is to deliver safe and quality nursing care to patients on intravenous therapy (IV). This directly ties the purpose of the program to the real-world outcome it seeks to achieve - providing optimal care for patients requiring intravenous therapy. Ensuring safe practice in the hospital (Option A) is important but it is not specific to the focus of the IV therapy program. Improving nursing practice in general (Option B) is a noble goal but the program should have a specific and targeted objective. Providing knowledge and skills to all nursing staff in IV Therapy (Option C) is essential, but the primary aim should be centered on improving patient care outcomes. Therefore, delivering safe and quality nursing care to patients on IV therapy aligns most closely with the core purpose of the program and should be the primary rationale.

Correct Answer: B

Rationale: The nurse should provide accurate information about the medication, including potential side effects, to address the patient's concerns. It is important for the nurse to listen to the patient's worries and provide them with the knowledge they need to make an informed decision about their treatment. By educating the patient about the medication and its potential side effects, the nurse empowers the patient to be actively involved in their care and promotes shared decision-making. Disregarding the patient's concerns, encouraging them to stop taking the medication, or minimizing the importance of their worries are not appropriate responses and may negatively impact the patient-nurse relationship and the patient's adherence to the prescribed treatment.

Correct Answer: C

Rationale: Clients undergoing nasogastric suctioning are at highest risk for developing metabolic imbalances, specifically metabolic acidosis. Nasogastric suctioning can lead to the loss of gastric acid, which in turn can cause metabolic acidosis due to a decrease in bicarbonate levels in the body. This disruption in the acid-base balance can result in symptoms such as confusion, headache, and overall malaise. It is crucial for the nurse to monitor the client's acid-base status closely and provide appropriate interventions to prevent or correct metabolic acidosis.

Correct Answer: D

Rationale: Escherichia coli (E. coli) is the MOST common causative agent of urinary tract infection (UTI), accounting for approximately 80-85% of all cases. E. coli is a type of bacteria that naturally resides in the gastrointestinal tract and can easily migrate to the urinary tract, causing infection. Its prevalence in UTIs is due to various factors such as its ability to adhere to the uroepithelial cells and form biofilms, leading to persistent infections. Therefore, E. coli is the most common organism responsible for UTIs in both community and healthcare settings.

Correct Answer: A

Rationale: Utilitarianism is an ethical theory that focuses on producing the greatest overall balance of good over bad consequences for everyone involved. In the context of the situation described, nurses being floated to areas of most need during a nursing shortage is an example of utilitarianism in action. The decision to float nurses is aimed at maximizing the benefit to the greatest number of patients by ensuring that critical care is provided where it is most needed, even if it may cause inconvenience or discomfort to the nurses being floated. This decision aligns with the principle of maximizing overall utility and promoting the greater good, which are central tenets of utilitarianism.

Correct Answer: B

Rationale: The formulation of a vision and mission statement in a health facility is an essential aspect of leadership and management. A well-crafted vision and mission statement provide the organization with a clear direction and purpose, guiding management and health personnel in their daily activities. It helps in aligning individual goals with organizational objectives, fostering teamwork, and enhancing overall performance. Effective leadership and management ensure that the vision and mission are communicated effectively, understood by all stakeholders, and implemented throughout the organization to achieve quality standards. By setting the tone for organizational culture and values, leadership and management play a crucial role in shaping the quality of care and services provided by the health facility.