Which of the following interventions is most appropriate for a patient with a tension pneumothorax?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.

Correct Answer: D

Rationale: Ovarian torsion is the most likely cause of the pregnant woman's symptoms as described. Ovarian torsion occurs when the ovary twists on its pedicle, leading to compromised blood flow to the ovary. This can cause severe abdominal pain, bloating, and constipation. On examination, an abdominal mass may be palpable due to an enlarged, twisted ovary. Bowel sounds may be diminished due to the effect of the torsion on surrounding structures. Ectopic pregnancy, threatened abortion, and placenta previa are less likely to present with an abdominal mass and diminished bowel sounds.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: Sundowning is a phenomenon commonly seen in elderly individuals, particularly those with cognitive impairments like dementia, where they become more restless, anxious, confused, or agitated during late afternoon and evening hours, typically around sunset. This change in behavior can manifest as increased confusion, wandering, aggression, or vocalization. The exact cause of sundowning is not completely understood but may involve a combination of factors such as disruptions in the sleep-wake cycle, fatigue, decreased lighting, and hormonal imbalances. Managing sundowning behaviors may involve environmental modifications, maintaining a regular routine, ensuring proper lighting, and addressing any underlying medical conditions contributing to the behavior changes.

Correct Answer: D

Rationale: Nurse Noli should not advise patients to eat more saturated fats. Saturated fats are known to increase cholesterol levels and can lead to heart disease and other health issues. It is recommended to limit the intake of saturated fats in the diet. Therefore, advising patients to eat more saturated fats goes against the goal of promoting heart-healthy habits. Instead, Nurse Noli should focus on encouraging patients to cut down on salt intake, consume more fruits and vegetables, and eat regular meals to maintain a balanced and healthy diet.

Correct Answer: C

Rationale: The most commonly associated adverse effect with ACE inhibitors is a dry cough. This cough is non-productive and can be quite bothersome for patients, often leading to non-compliance with the medication. The cough is thought to be due to the accumulation of bradykinin and substance P, which are vasodilatory and bronchoconstrictive peptides that are normally degraded by ACE. When ACE is inhibited, these peptides accumulate and can lead to irritation of the respiratory tract, resulting in the dry cough. It's important for healthcare providers to be aware of this common side effect and consider alternative medications if the cough becomes problematic for the patient.

Correct Answer: A

Rationale: The appropriate approach of the nurse in this situation would be to talk about the reality of death with the father. It is important to provide appropriate and compassionate communication, acknowledging the father's grief while also gently guiding him towards accepting the reality of the situation. By discussing the reality of death and offering support, the nurse can help the father start the grieving process and eventually come to terms with the loss of his son. It is important to provide emotional support and guidance in a sensitive and respectful manner during such a difficult time.

Correct Answer: C

Rationale: The PRIORITY nursing action of the nurse for Jose due for oxygen therapy is to turn on the oxygen. Ensuring that the oxygen is turned on is the necessary first step before any other actions can be effective in delivering oxygen to the patient. Without oxygen being turned on, all other steps such as attaching the humidifier, connecting tubing, or adjusting the flow rate would be ineffective in providing the necessary oxygen therapy to the patient. Therefore, turning on the oxygen is the most crucial initial step to take in this situation to ensure that the patient receives the needed oxygen promptly and safely.