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 ["C","E","F"]
Explanation
Rationale:
A. Defense mechanisms and coping strategies are not the same. Defense mechanisms are unconscious processes used to protect the individual from anxiety and internal conflicts, while coping strategies are conscious efforts to handle stress.
B. Defense mechanisms can be maladaptive and may not always help clients positively deal with stress. They can sometimes hinder adaptive functioning.
C. Defense mechanisms are indeed influenced by neurological and psychological growth. As individuals age, they develop more sophisticated and adaptive mechanisms.
D. Maladaptive defense mechanisms do not improve mental well-being; instead, they can often worsen mental health and impair functioning.
E. Adaptive defense mechanisms, such as sublimation and rationalization, help individuals manage stress more effectively and transform challenges into manageable situations.
F. Adaptive defense mechanisms are characteristic of more mature psychological functioning, reflecting a higher level of emotional resilience and coping.
Correct Answer is ["B","D","E","F"]
Explanation
Rationale:
A. The ECG shows persistent sinus bradycardia on both December 1 and December 15. While sinus bradycardia is common in anorexia nervosa, its persistence may not necessarily reflect a therapeutic response.
B. The respiratory rate improved from 24/min to 20/min and the respirations are described as even and unlabored on December 15. This indicates a positive response to treatment.
C. The temperature data for December 15 is not provided. However, an increase toward normal temperature would indicate a therapeutic response, but without this data, we cannot confirm.
D. The weight increased from 34.5 kg (76 lb) to 37.2 kg (82 lb), which is a significant therapeutic improvement, reflecting progress in treatment.
E. The sodium level improved from 128 mEq/L to 130 mEq/L. Although the level is still slightly below normal, the upward trend indicates improvement.
F. The creatinine level decreased from 1.2 mg/dL to 0.9 mg/dL, showing improvement in kidney function and response to treatment.