Which of the following actions is indicated in the management of a patient with an open chest wound (sucking chest wound)?

Correct Answer: A

Rationale: An open chest wound, also known as a sucking chest wound, can lead to a collapsed lung and respiratory distress. Immediate management involves sealing the wound to prevent air from entering the pleural space and further compromising the patient's respiratory function. Applying a sterile dressing over the wound helps to prevent contamination and occluding the wound with an airtight covering, such as an occlusive dressing, can effectively reduce the risk of a tension pneumothorax, a serious complication that can arise from a sucking chest wound. These interventions help to stabilize the patient's condition and improve the chances of a successful recovery. Administering supplemental oxygen, though beneficial, would be secondary to the primary management of sealing the chest wound. Providing emotional support is important but addressing the physical emergency takes precedence. Elevating the patient's legs would not be appropriate in managing an open chest wound.

Correct Answer: A

Rationale: Research at work is an example of self-directed learning activity because it involves taking the initiative to seek out information, learn new skills, and solve problems independently within a workplace setting. This type of learning requires self-motivation, self-discipline, and autonomy to set goals, gather resources, and develop knowledge or expertise in a specific area. Individuals engage in research at work to enhance their professional growth, expand their skill set, or address challenges encountered in their job responsibilities. It is a proactive approach to learning where individuals take charge of their own development and continuously strive to improve their performance.

Correct Answer: B

Rationale: The nurse's best response in this situation is to listen actively to the patient's concerns, acknowledge the inconvenience they are experiencing, and offer support. It is essential to validate the patient's feelings and show empathy towards their frustration. By actively listening and addressing the patient's concerns, the nurse can help alleviate some of their frustration and build a positive rapport with the patient. This approach demonstrates respect for the patient's feelings and promotes effective communication in the healthcare setting. Dismissing or ignoring the patient's frustration can lead to further dissatisfaction and impact the quality of care provided.

Correct Answer: C

Rationale: Intracerebral hemorrhage occurs when there is bleeding directly into the brain tissue, often due to conditions such as hypertension or vascular malformations. The sudden-onset severe headache, altered mental status, and focal neurological deficits described in the patient are typical symptoms of an intracerebral hemorrhage. The location of the hemorrhagic lesion within the right basal ganglia corresponds to the clinical presentation. Ischemic stroke, subarachnoid hemorrhage, and transient ischemic attack (TIA) typically have different presentations and imaging findings compared to an intracerebral hemorrhage. Therefore, in this scenario, intracerebral hemorrhage is the most likely cause of the patient's symptoms.

Correct Answer: A

Rationale: The client is exhibiting signs and symptoms of respiratory alkalosis. When a person is experiencing respiratory alkalosis, there is an excessive loss of carbon dioxide (CO2) from the body, leading to elevated blood pH. The marked increase in the rate and depth of respirations as well as symptoms of anxiety, restlessness, and irritability are characteristic of respiratory alkalosis. This condition can be caused by hyperventilation, anxiety, or fever, which result in excessive elimination of CO2 from the body, leading to an imbalance in the acid-base status. Treatment for respiratory alkalosis involves addressing the underlying cause, such as providing reassurance to decrease anxiety or managing the breathing pattern to normalize CO2 levels.

Correct Answer: B

Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.

Correct Answer: C

Rationale: Mrs. Juan's therapeutic treatment should focus on redirecting her energy into activities that involve helping others. By engaging in altruistic activities, Mrs. Juan can shift her focus away from her fears and anxieties towards something positive and fulfilling. This approach can help her to find purpose and meaning outside of her own concerns, fostering a sense of well-being and satisfaction. Additionally, helping others can provide Mrs. Juan with a sense of accomplishment and self-worth, ultimately contributing to her overall mental health and emotional resilience.

Correct Answer: A

Rationale: The patient is presenting with chest pain that worsens with exertion and improves with rest, which is characteristic of stable angina. Additionally, ST-segment depression on ECG is a common finding in patients with stable angina. Stable angina is typically caused by coronary artery disease, which leads to partial obstruction of the coronary arteries resulting in inadequate blood flow to the heart muscle during periods of increased demand (such as exertion). The chest pain is usually predictable and reproducible, occurring with similar intensity and duration during episodes of exertion. Rest or nitroglycerin can help relieve the symptoms by increasing coronary blood flow. It is important to differentiate stable angina from unstable angina and acute myocardial infarction, which have different management and prognostic implications.

Correct Answer: C

Rationale: Beta-adrenergic agonists stimulate beta-adrenergic receptors in the heart, leading to an increase in heart rate (tachycardia). This is a common adverse effect associated with the use of beta-adrenergic agonists in the management of conditions such as asthma. Monitoring for tachycardia is important because it can potentially lead to other complications such as palpitations, arrhythmias, and exacerbation of underlying cardiovascular conditions. It is essential for the nurse to closely monitor the patient for any signs or symptoms of tachycardia and report any abnormalities to the healthcare provider promptly to ensure appropriate management and prevent further complications.