The medical-surgical nurse, who cares for a patient newly diagnosed with cancer, observes the patient becoming angry with the physicians and nursing staff. The best approach to diffuse the emotionally charged discussion is to

Correct Answer: C

Rationale: The correct answer is C: direct the discussion and validation of emotion, without false reassurance. This approach is the most appropriate because it acknowledges the patient's emotions without dismissing them or providing false reassurance. When caring for a patient newly diagnosed with cancer, it is crucial to address their emotional responses such as anger in a supportive and validating manner. By actively listening, acknowledging the patient's feelings, and providing a safe space for expression, the nurse can help the patient navigate their emotions and feel understood. Option A: Allowing the patient and family members time to be alone may not address the underlying issue of the patient's anger and may even lead to further isolation and frustration. Option B: Arranging time for the patient to speak with another patient with cancer might be beneficial for peer support, but in this scenario, the patient's immediate emotional needs and the interaction with the healthcare team need to be addressed first. Option D: Requesting a consultation from a social worker on the oncology unit may be helpful for long-term support, but in the moment, the nurse should directly engage with the patient to address the current emotional distress. In an educational context, this question highlights the importance of therapeutic communication skills in managing the emotional responses of patients with cancer. Nurses need to be able to effectively navigate and validate a range of emotions expressed by patients to provide holistic care and support during challenging times.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Cough and deep breathe every 2 hours. This intervention is crucial for a client with acute pancreatitis because it helps prevent atelectasis by promoting lung expansion and increasing oxygenation. Clients with acute pancreatitis are at risk for respiratory complications due to the proximity of the pancreas to the diaphragm and the potential for inflammation to affect lung function. Therefore, maintaining respiratory function is a priority in their care. Option B) Place the client in contact isolation is incorrect because acute pancreatitis is not a contagious condition that requires isolation precautions. Isolating the client unnecessarily could lead to feelings of social isolation and impact their emotional well-being. Option C) Provide a diet high in protein is incorrect because during the acute phase of pancreatitis, the client should be on a clear liquid diet or NPO (nothing by mouth) to rest the pancreas and reduce pancreatic stimulation. Introducing a high-protein diet at this stage can exacerbate the condition. Option D) Institute seizure precautions is incorrect because seizures are not a common complication of acute pancreatitis. Instituting seizure precautions without a specific indication can lead to unnecessary restrictions on the client's mobility and autonomy. In an educational context, understanding the rationale behind each intervention is crucial for nurses caring for clients with acute pancreatitis. By prioritizing interventions based on the client's condition and needs, nurses can provide safe and effective care that promotes optimal outcomes for the client's health.

Correct Answer: B

Rationale: The correct intervention in this scenario is option B) Opening the bottom of the pouch, allowing the flatus to be expelled. This is the correct choice because opening the bottom of the pouch is the appropriate method to release flatus without compromising the integrity of the ostomy pouch or risking contamination. By opening the pouch, the flatus can be easily and safely expelled without causing any harm to the client or the pouch. Option A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus is incorrect because it can introduce infection or damage the pouch, leading to leakage. Option C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape is also incorrect as it can compromise the seal and lead to leakage. Option D) Assisting the client to ambulate to reduce the flatus in the pouch is incorrect as it does not address the immediate need to release the flatus from the pouch. In an educational context, it is essential for nurses to understand the proper care and management of ostomy pouches to ensure the comfort and well-being of clients with ostomies. Knowing the correct interventions for common issues like flatus management is crucial in providing effective and safe care to clients with ostomies.

Correct Answer: D

Rationale: Rationale: The correct answer is D) Administer oxygen. In a client with congestive heart failure experiencing severe shortness of breath, falling pulse oximetry, gray skin color, and pink frothy sputum, the priority is to address the impaired oxygenation by providing oxygen. Administering oxygen will help improve oxygen saturation levels and support the client's respiratory function, which is crucial in this emergent situation. Option A) Call the health care provider can delay immediate intervention. In a critical situation like this, the nurse must act promptly to stabilize the client's condition before seeking further orders. Option B) Check vital signs is important, but providing oxygen takes precedence in addressing the client's acute respiratory distress. Option C) Position in high Fowler's is a supportive measure but does not address the immediate need for oxygenation in a client with severe respiratory distress. In an educational context, this scenario emphasizes the importance of prioritizing interventions based on the client's condition. Nurses must quickly assess and intervene in acute situations to ensure the best outcomes for their patients. Understanding the critical nature of respiratory distress in clients with heart failure is essential for nurses working in medical-surgical settings.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Ileostomy. An ileostomy poses the highest risk for skin breakdown among the given stomal diversions. This is because an ileostomy produces effluent that is liquid and highly corrosive, containing digestive enzymes that can irritate and damage the skin surrounding the stoma more easily than a more formed stool. In contrast, the other options present lower risk for skin breakdown: - Transverse colostomy: Produces formed stool, posing less risk for skin irritation. - Ileal conduit: Typically used for urinary diversion, not fecal diversion, so skin breakdown is not a prominent concern. - Sigmoid colostomy: Produces more formed stool compared to an ileostomy, reducing the risk of skin breakdown. Educationally, understanding the characteristics of different stomal diversions is crucial for nurses providing care to clients with stomas. Proper stoma care techniques, including assessment, cleansing, and skin protection, are essential to prevent skin breakdown and maintain the client's skin integrity and overall well-being. Nurses should be knowledgeable about the specific risks associated with each type of stoma to provide individualized care and prevent complications.