Which of the following health teaching concern for the nurse as discharged plan for suicidal patient who had been taking tricyclic antidepressant drugs for 2 weeks and now ready to go home?

Correct Answer: C

Rationale: When discharging a suicidal patient who has been taking tricyclic antidepressant drugs, it is crucial for the nurse to evaluate the risk for suicide by overdose of the medication. Tricyclic antidepressants have a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose can be quite small. This makes them particularly dangerous in cases of overdose, as they can lead to severe toxic effects, including cardiac arrhythmias, seizures, and death.

Correct Answer: B

Rationale: Thrombotic thrombocytopenic purpura (TTP) is a rare blood disorder characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, neurological abnormalities, and renal dysfunction. The peripheral blood smear in TTP typically shows fragmented red blood cells (schistocytes) due to mechanical destruction within small blood vessels. Laboratory findings in TTP commonly include elevated lactate dehydrogenase (LDH), decreased haptoglobin (as it is consumed in the clearance of free hemoglobin), and increased indirect bilirubin due to increased red blood cell breakdown. This combination of clinical presentation and laboratory abnormalities is classic for TTP. Hemolytic uremic syndrome (HUS) may present similarly but is more commonly associated with renal dysfunction and is often triggered by infection with Shiga toxin-producing E. coli.

Correct Answer: A

Rationale: When a patient is in a somnolent status and still under the effect of anesthesia, the most appropriate position to place the patient is in a supine position with the head of the bed slightly elevated. This position helps prevent any obstruction of the airway and promotes optimal ventilation. Elevating the head of the bed ensures that the patient's airway remains clear and allows for proper breathing. Additionally, this position helps prevent aspiration and promotes proper circulation. Overall, the supine position with the head bed slightly elevated is the safest and most effective position for a patient in this condition.

Correct Answer: D

Rationale: All of the components -explanation of the procedure and alternatives to the procedure (I), discussion of potential risks and benefits of the procedure (II), and confirmation that the patient understands the risks, benefits, and any alterations (III) -are essential parts of informed consent. Providing information about the procedure and its alternatives, disclosing potential risks and benefits, and ensuring that the patient comprehends this information are crucial to obtaining valid informed consent prior to any medical procedure.

Correct Answer: D

Rationale: Nurse Parker functioned independently when she initiated the visit by arranging for the clergy to see patient Ximena. In this scenario, the nurse took the initiative on her own without needing approval or direction from others. She recognized the patient's request for spiritual guidance and took independent action to meet that need. Independently functioning in this context demonstrates the nurse's autonomy and ability to make decisions based on the patient's preferences and well-being.

Correct Answer: A

Rationale: Transient ischemic attack (TIA) is a temporary episode of neurological dysfunction caused by a temporary disruption in blood supply to the brain. The symptoms of a TIA typically last for a short period of time, usually less than 1 hour. In some cases, the symptoms may last up to 24 hours but generally resolve within a shorter time frame. It is important for healthcare providers to recognize the symptoms of a TIA promptly and assess the patient for appropriate management to prevent the risk of a full-blown stroke.

Correct Answer: D

Rationale: The desired nursing action to help the pregnant patient make a decision on breastfeeding is to assist in identifying a breastfeeding goal and plan. When patients are indecisive about breastfeeding, it is essential for the nurse to support them in setting specific goals and creating a plan that aligns with their values and circumstances. This approach can help the patient feel empowered and confident in their decision-making process. Providing pamphlets and books (choice A) may be helpful, but personalized assistance in identifying a breastfeeding goal and plan is more likely to address the patient's individual needs and concerns. Providing ample time for the patient to decide (choice B) is important, but guidance and support in setting a clear goal can facilitate the decision-making process. Referring the patient to a nutritionist (choice C) may be beneficial for dietary concerns but may not directly address the decision-making process regarding breastfeeding.

Correct Answer: C

Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.

Correct Answer: D

Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.