What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?

Correct Answer: B

Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.

Correct Answer: B

Rationale: The patient's presentation of sudden-onset weakness and sensory loss on one side of the body, along with difficulty speaking and understanding speech that partially resolved within one hour, is consistent with a transient ischemic attack (TIA). TIAs are caused by temporary disruption of blood flow to a part of the brain, leading to transient neurological symptoms. Unlike an ischemic stroke, which results in permanent damage to brain tissue due to prolonged interruption of blood flow, TIAs are transient and resolve within 24 hours. Hemorrhagic strokes and subarachnoid hemorrhages typically present with sudden, severe headaches, and may not improve or resolve quickly as seen in this case.

Correct Answer: B

Rationale: The epigastrium is the upper middle region of the abdomen, lying above the umbilical region and between the hypochondriac regions. It contains several organs including the duodenum, pancreas, portion of the liver, and the pyloric end of the stomach. The duodenum is the first part of the small intestine, the pancreas is a crucial organ for digestion and hormone regulation, the liver aids in digestion and detoxification, and the pyloric end of the stomach connects the stomach to the small intestine for further digestion and absorption of nutrients. These organs are typically assessed and examined when focusing on the epigastrium during a physical examination.

Correct Answer: A

Rationale: The best response of Nurse Virgo is to explain to Patient Benito that his body needs to function well with his pancreas. The pancreas plays a critical role in the digestive system by producing digestive enzymes and hormones that help regulate blood sugar levels. Removing the pancreas would result in serious health consequences and complications, as the body relies on it for essential functions. It is important for the patient to understand the significance of the pancreas and why its removal is not a viable solution.

Correct Answer: C

Rationale: The nurse should obtain interpreter services or language assistance as needed to ensure effective communication with a patient who has limited English proficiency. Using an interpreter will facilitate clear and accurate communication between the nurse and the patient, enabling the patient to fully understand their care, treatment, and any instructions provided. Speaking loudly or slowly, using medical jargon, or ignoring the language barriers are not effective strategies for communicating with a patient who has limited English proficiency. Utilizing interpreter services demonstrates respect for the patient's language and cultural needs, which is essential for providing high-quality care.

Correct Answer: D

Rationale: In the scenario described, the patient is experiencing severe hypoxemia refractory to conventional oxygen therapy, indicating a need for advanced respiratory support. When a patient with ARDS fails to respond to conservative management, including mechanical ventilation strategies, prone positioning, and recruitment maneuvers, the next step may involve extracorporeal membrane oxygenation (ECMO). ECMO provides a way to bypass the lungs and oxygenate the blood directly, allowing for enhanced gas exchange and support for severely compromised respiratory function. Therefore, in this critical situation, prioritizing the recommendation for ECMO can offer the patient the best chance of improving oxygenation and survival.

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.

Correct Answer: C

Rationale: In cases of persistent fetal malpresentation, such as a transverse lie position, a cesarean section is often the safest and most effective intervention to address the abnormal labor presentation. Delivering a baby in a transverse lie position vaginally is associated with high risks, including fetal complications such as umbilical cord prolapse and head entrapment. Therefore, to ensure the safety of both the mother and the baby, a cesarean section is usually the most appropriate and timely intervention to address this situation. It is crucial to prioritize the immediate preparation and facilitation of a cesarean section in cases of persistent fetal malpresentation to prevent potential complications and ensure the best outcome for the mother and the baby.

Correct Answer: B

Rationale: The 5's strategy to prevent dengue infection includes Search and Destroy mosquito breeding places, seek early consultation at the nearest health care facility, say no to fogging spraying, and misting in hot spot areas. While using mosquito repellent on exposed skin is a common preventive measure against mosquito bites, applying it all over your body is not included in the official 5's strategy for dengue prevention. The focus of the 5's strategy is on eliminating mosquito breeding sites, seeking medical advice early in case of symptoms, and avoiding certain mosquito control methods like fogging in hot spot areas.