What is the M0ST APPROPRIATE nursing diagnosis for this patient?

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.

Correct Answer: C

Rationale: The priority nursing intervention to promote optimal wound healing in a client who had an episiotomy is providing perineal care using peri-bottles with warm water. Warm water helps to cleanse the area, reduce the risk of infection, and promote circulation, which aids in wound healing. Peri-bottles are especially gentle and effective in cleaning the perineal area without causing trauma to the incision site. Encouraging frequent perineal hygiene with soap and water may be too harsh on the incision site and could lead to irritation. Applying antibiotic ointment after each void is not necessary unless prescribed by the healthcare provider, as overuse of antibiotics can lead to resistance. Instructing the client on proper peri-pad application is important for comfort and cleanliness but is not as crucial as gentle perineal care using peri-bottles with warm water for promoting optimal wound healing.

Correct Answer: B

Rationale: Running water in the sink or shower is a priority nursing measure to stimulate the sensation of voiding in postpartum mothers experiencing difficulty due to edema and trauma of the perineum. The sound and sight of running water can help relax the pelvic floor muscles and trigger the urge to void. This technique is commonly used in clinical practice to facilitate voiding and prevent urinary retention in postpartum women.

Correct Answer: A

Rationale: Administering intravenous fluids as ordered is the most appropriate nursing action for a postpartum client exhibiting signs of severe dehydration. Severe dehydration, as indicated by dry mucous membranes, decreased skin turgor, and oliguria, requires immediate intervention to restore fluid balance effectively. Intravenous fluids deliver fluids directly into the bloodstream, ensuring rapid rehydration and addressing the critical situation promptly. Offering oral rehydration solutions may not be sufficient to address severe dehydration, and providing education on fluid intake can be important for prevention but is not the immediate priority in this scenario. Notifying the healthcare provider is essential, but initiating intravenous fluids promptly is crucial in managing severe dehydration.

Correct Answer: D

Rationale: An example of what can be elicited from a social history is how the disease started. This statement is true because a social history typically includes information about factors such as the onset of the illness, the child's living environment, family dynamics, and any recent events that may have contributed to the child's current condition. Understanding how the disease started can provide valuable insights into possible triggers or underlying causes, helping healthcare providers develop an appropriate treatment plan. A comprehensive social history is essential for providing holistic care to the child and addressing all relevant factors that may impact their health and well-being.

Correct Answer: A

Rationale: The patient's symptoms of fever, chills, headache, and myalgia after returning from sub-Saharan Africa are consistent with malaria. Intraerythrocytic ring forms and trophozoites observed on blood smear examination are characteristic of Plasmodium species, particularly Plasmodium falciparum, which is the most common and deadliest species causing malaria in sub-Saharan Africa. Plasmodium falciparum can lead to severe complications, such as cerebral malaria, if not promptly treated. Trypanosoma cruzi causes Chagas disease, not malaria. Borrelia burgdorferi is responsible for Lyme disease, which typically presents with a different set of symptoms like erythema migrans rash. Leishmania donovani causes visceral leishmaniasis, not malaria.

Correct Answer: C

Rationale: Verbal communication involves the use of words and language to convey information. The content refers to the actual words and messages being communicated. In verbal communication with your patient, the content of what you say is key to ensuring effective communication that is clear, accurate, and easily understood. Therefore, the use of literal words when speaking to your patient embodies the content of your communication.

Correct Answer: A

Rationale: As a QA nurse, Nurse Jen can adopt concurrent evaluation methods to assess patient outcomes in the unit. The most appropriate options for concurrent evaluation are Face to face interview with nursing staff (III) and Nursing audit from the patient's chart (IV).

Correct Answer: B

Rationale: The medication given after a successful vaginal delivery that helps to hasten uterine contractility and control bleeding is typically an oxytocic agent, such as oxytocin. Oxytocin helps the uterus to contract effectively, which is important for preventing excessive bleeding after delivery. This medication is commonly used in the postpartum period to help the uterus return to its normal size and position. The supervisor reassured the newly hired nurse that everything will be fine because this medication will help promote uterine contractions and control bleeding, which are crucial steps in the postpartum management.