A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Skin color
Hemoglobin level
Fluid intake
Temperature
The Correct Answer is B
Rationale:
A. While skin color may be an indicator of overall health, it is not the most crucial data point before administering packed RBCs.
B. The hemoglobin level is the most important data to assess before administering packed RBCs, as it provides direct information about the client’s need for the blood transfusion and helps evaluate the effectiveness of the intervention.
C. Fluid intake is important in overall client assessment but is not as immediately relevant as hemoglobin levels when preparing to administer packed RBCs.
D. Temperature should be monitored to check for any signs of infection, but it is not the primary concern when deciding to proceed with a blood transfusion.
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Correct Answer is D
Explanation
Rationale:
A. An elevated heart rate alone is not commonly associated with depression.
B. While renal dysfunction can impact mood, the direct link between it and depression is not as strong as other factors.
C. High blood pressure is not a direct cause of depression, though it can contribute to overall health issues.
D. Stress from a new job is a common and recognizable factor that can lead to or exacerbate depressive symptoms, showing an understanding of how situational stress can impact mood.
Correct Answer is C
Explanation
Rationale:
A. Narrative therapy is a therapeutic approach that focuses on reshaping personal narratives and is not typically associated with increased risk of self-harm.
B. Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder manage self-harm behaviors and emotional dysregulation, so it would generally reduce, not increase, risk.
C. The period following hospital discharge is often associated with a higher risk of self-harm due to potential lack of support, instability, or feelings of abandonment.
D. While significant life events such as getting married can be stressful, they are not typically associated with the highest risk of self-harm compared to the transitional phase post-discharge.