The nurse informs the patient and family that rehabilitation prior to discharge is BEST described as______.

Correct Answer: A

Rationale: Rehabilitation prior to discharge is best described as a period of ups and downs, physically and emotionally because it involves the recovery process after an illness, injury, or medical procedure. It is a challenging time where the patient may experience setbacks and improvements on their journey back to health. There can be physical challenges such as regaining strength and mobility, as well as emotional challenges like coping with the changes in their condition. Therefore, the rehabilitation process is often not smooth and can be a rollercoaster of progress and setbacks, both physically and emotionally.

Correct Answer: B

Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.

Correct Answer: B

Rationale: The correct charting rule to keep the nurse legally safe is to document worries and all concerns as verbalized by the patient (Choice I). This is important for accurately reflecting the patient's condition, communication, and potential interventions. Charting at the end of the shift only (Choice II) is not recommended as it can lead to missed important details or delayed documentation. Discussing recorded cases and diagnoses of the patient (Choice III) breaches patient confidentiality and violates HIPAA laws. Recording all information verbalized by the patient and family (Choice IV) may include unnecessary details and could potentially lead to misinterpretation or misunderstanding, which might not be legally advantageous.

Correct Answer: C

Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).

Correct Answer: D

Rationale: When a postpartum client exhibits signs of postpartum psychosis such as hallucinations, delusions, and disorganized behavior, it is crucial to involve the healthcare provider immediately. Postpartum psychosis is a psychiatric emergency that requires prompt assessment and intervention by mental health professionals. The healthcare provider can determine the appropriate course of action, which may include hospitalization, medication management, and specialized psychiatric care. Delaying notification can lead to serious consequences for both the client and her infant, so timely intervention is essential in managing postpartum psychosis.