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: 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: A

Rationale: Establishing a regular routine can be very helpful in stabilizing the mental state of parents. Consistency and structure in day-to-day activities can provide a sense of predictability and control, which can help reduce anxiety and stress. By having a routine, the parents can feel more organized, efficient, and better equipped to manage their responsibilities and emotions. Additionally, a regular routine can promote better sleep patterns, healthier habits, and overall well-being. This measure is practical, achievable, and can have positive effects on the mental stability of Nurse Lailanie's parents.

Correct Answer: A

Rationale: The initial treatment goal for a patient like Mila is often focused on preventing infection. Infection prevention is a basic and essential step in patient care, especially for someone who may be at risk due to their medical condition or treatment plan. By preventing infection, healthcare providers can help ensure the patient's safety and promote successful outcomes for the overall treatment plan. Correcting hypoxia, metabolic acidosis, and increasing myocardial oxygen supply may be important goals as well, but preventing infection is usually prioritized as it can have serious consequences if not addressed promptly.

Correct Answer: A

Rationale: The correct statement that indicates the teaching goal has been met is when the client says, "The spray should be used round-the-clock at equally spaced intervals." This statement shows an understanding of how to properly use the decongestant nasal spray as instructed by the nurse. Using the spray round-the-clock at equally spaced intervals helps maintain consistent relief from congestion without the risk of overuse or rebound effects. This response indicates that the client has grasped the correct usage instructions for the decongestant nasal spray, which is the goal of the teaching.