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
Explanation
Rationale:
A. HIV infection can cause cognitive impairment, but it typically does not present with fluctuating cognition and visual hallucinations as primary symptoms.
B. Traumatic brain injury can lead to cognitive changes, but it is not typically associated with fluctuating cognition and visual hallucinations.
C. Lewy body disease is characterized by fluctuating cognition, visual hallucinations, and motor symptoms, making it the most likely diagnosis for these symptoms.
D. Prion disease is associated with rapidly progressive dementia but not specifically with fluctuating cognition and visual hallucinations.
Correct Answer is A
Explanation
Rationale:
A. Offering information about a support group is a supportive measure that can help the client manage their condition while parenting.
B. Encouraging children to visit the psychiatric unit may not be appropriate or therapeutic for the client or the children.
C. Suggesting that the children live with other relatives is a significant intervention that may not be necessary without further assessment.
D. Notifying child protective services is not warranted unless there is clear evidence of child neglect or abuse.