While Mrs. Mely is on TPN she suddenly complained of slight chest pain, dyspnea and appears cyanotic. You suspect that she is experiencing what possible IMMEDIATE complication?

Correct Answer: C

Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.

Correct Answer: A

Rationale: Acute respiratory distress syndrome (ARDS) is a serious and life-threatening condition characterized by rapid onset of respiratory failure, severe hypoxemia (low oxygen levels in the blood), and non-cardiogenic pulmonary edema. The hallmark of ARDS is severe hypoxemia that is difficult to correct even with high levels of supplemental oxygen. Patients with ARDS often require mechanical ventilation to maintain adequate oxygen levels. Severe cough with purulent sputum production, chest pain exacerbated by deep breathing, and productive cough with hemoptysis are not typical features of ARDS.

Correct Answer: B

Rationale: The Right to Information pertains to the patient's right to be informed about their condition, treatment plan, and to have access to relevant medical information. It does not include specific details about payment or insurance coverage, such as the extent to which payment may be expected from PhilHealth. While financial information is important for patients, it does not fall under the scope of the Right to Information in a healthcare context, which focuses more on medical information and decision-making processes.

Correct Answer: C

Rationale: The primary collaborative goal for the treatment of Ms. C should be to restore normal nutrition and weight. This is essential in addressing the potential health issues associated with anorexia nervosa, which is characterized by significantly low body weight and malnutrition. By focusing on restoring normal nutrition and weight, Ms. C can improve her physical health and overall well-being. Resolving possible dysfunctional family roles as an adolescent, increasing the desire to eat, and assisting her to increase feelings of control over eating are important aspects of treatment as well, but the most immediate goal should be to address the physical consequences of anorexia nervosa through restoring normal nutrition and weight.

Correct Answer: B

Rationale: In cases of acute intracerebral hemorrhage (ICH) with elevated intracranial pressure (ICP), a significant factor contributing to the elevated ICP is often the mass effect caused by the hematoma within the brain. Performing an emergent craniotomy for hematoma evacuation is a critical intervention to relieve the pressure within the intracranial space, thereby mitigating the risk of herniation and further neurological damage. While other interventions such as hypertonic saline therapy, head-of-bed elevation, and sedative medications may have supporting roles in managing ICP, none address the primary cause of elevated ICP in cases of acute intracerebral hemorrhage as effectively as hematoma evacuation through craniotomy.

Correct Answer: C

Rationale: The symptoms of polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger) are classic signs of diabetes mellitus. In this case, the presence of hyperglycemia (high blood sugar) and glycosuria (glucose in the urine) further support the diagnosis of diabetes mellitus. Insulin deficiency or resistance in diabetes leads to impaired glucose utilization and excessive glucose in the bloodstream, causing the classic symptoms observed in the patient. Hyperthyroidism, hypothyroidism, and Cushing's syndrome do not typically present with the hallmark symptoms of polyuria, polydipsia, and polyphagia associated with uncontrolled diabetes mellitus.

Correct Answer: D

Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.

Correct Answer: B

Rationale: The importance of validation in the context of communication and nursing care does not include the assumption that most patients are cognitively impaired. It would be more appropriate to approach patient interactions with the assumption that patients are capable of understanding and coherent communication. Validation is important because it helps ensure that the nurse has truly understood the patient's message, prevents misinterpretation, and fosters a sense of empathy and trust in the nurse-patient relationship. Additionally, validating the patient's thoughts and feelings can help clarify confused thoughts and promote effective communication. The other options (A, C, and D) are all valid reasons emphasizing the significance of validation in effective communication.

Correct Answer: B

Rationale: Negligence refers to the failure to act or perform duties according to the standard of care expected from a reasonable person in similar circumstances. In this case, Nurse Lina administering a penicillin injection that was ordered for another patient is a clear instance of negligence. It involves a breach of duty by not verifying the correct patient and medication before administration. While malpractice can also encompass negligence, it typically involves a broader scope of professional misconduct or harm caused by a healthcare provider. Assault and battery involve intentional harmful acts, which are not applicable in this situation.