Which intervention should the nurse use to promote rest?

Correct Answer: A

Rationale: Developing a routine with the patient to balance her studies and rest needs is the most appropriate intervention to promote rest. This approach considers the patient's responsibilities and can help her organize her time effectively to ensure she gets adequate rest while managing her studies. It acknowledges the importance of rest without completely disregarding the patient's other commitments, ultimately fostering a balanced approach to self-care. This intervention is patient-centered and collaborative, empowering the patient to take an active role in prioritizing rest alongside her educational responsibilities.

Correct Answer: D

Rationale: A hard mass and a reddened area on one breast are key clinical signs that confirm the diagnosis of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, and swelling of the breast. The presence of a hard mass along with the other symptoms suggests inflammation and infection within the breast tissue. In contrast, the other findings such as enlarged glands in the axilla, normal temperature, and engorged breasts are not specific findings for mastitis and may be present in other conditions. Therefore, the presence of a hard mass and reddened area on one breast is the additional finding that strongly confirms the diagnosis of mastitis in this case.

Correct Answer: B

Rationale: Digitalis therapy, commonly prescribed for heart conditions, is known for its narrow therapeutic range and potential for toxicity. In the case of Patient Lily, who has been on digitalis therapy since she was pregnant, the nurse would anticipate the continuation of the same dosage to maintain the therapeutic effects and reduce the risks of toxicity. It is essential to monitor the patient's digitalis levels regularly and adjust the dosage if necessary based on the patient's response and any changes in their clinical status. Switching to a more potent drug, changing the medication, or adding a diuretic would not be appropriate without further assessment and consultation with the healthcare provider managing Lily's digitalis therapy.

Correct Answer: C

Rationale: The primary nursing care delivery model is represented by option C, where the nurse performs all tasks needed by the individual patient to optimize health. In this model, the nurse is responsible for coordinating and providing comprehensive care to a specific group of patients throughout their stay. The primary nurse establishes a close relationship with the patient and takes accountability for their care, ensuring continuity, communication, and personalized attention. This approach emphasizes the importance of the nurse-patient relationship and holistic care delivery, which can lead to improved patient outcomes and satisfaction.

Correct Answer: B

Rationale: In the given situation, the nursing diagnosis that is NOT RELEVANT to sexual health is option B, Health-seeking behaviors related to reproductive functioning. This diagnosis focuses on the patient's proactive approach to seeking healthcare services related to reproductive health matters. However, in the situation presented of a pregnant patient with sickle cell anemia experiencing fever, painful swelling, and in labor pain, the immediate priority lies in addressing the health issues related to sickle cell disease and the current pregnancy. Sexual health is not the primary concern in this scenario compared to managing the complications of sickle cell anemia during pregnancy. Therefore, the diagnosis related to health-seeking behaviors related to reproductive functioning is not as pertinent in this specific case.