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 B
Explanation
Rationale:
A. A sense of power from restricting food intake is more indicative of anorexia nervosa, not bulimia nervosa.
B. An emotional high during binge-purge episodes is consistent with bulimia nervosa, as individuals with this disorder often experience a temporary sense of relief or pleasure during these episodes.
C. While bingeing and purging in secret can be a behavior seen in bulimia nervosa, the statement does not directly address the emotional aspects of the disorder.
D. Using laxatives solely for constipation is not specific to bulimia nervosa; it is a broader symptom management issue.
Correct Answer is D
Explanation
Rationale:
A. This statement may indicate prolonged grief or depression but does not specifically point to the guilt or distress seen in traumatic grief.
B. This describes a physiological response to flashbacks, which is more indicative of post-traumatic stress disorder (PTSD) rather than traumatic grief.
C. This statement reflects emotional suppression, which can be common in military culture but does not directly indicate traumatic grief.
D. Expressing survivor's guilt, as in feeling that they should have died instead of their friend, is a hallmark of traumatic grief and indicates the client is struggling with the loss in a deeply distressing way.