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. This response incorrectly defines suicide attempts and self-harm and oversimplifies the concept of self-harm.
B. A suicide attempt involves self-harm with the intent to die, whereas self-harm (or self-injury) involves harming oneself without the intention of death. This response accurately differentiates between the two.
C. Suicide attempts can involve self-harm, but not all self-harm is intended as a suicide attempt. This response conflates the terms.
D. The terms are not interchangeable; understanding their differences is crucial for accurate assessment and intervention.
Correct Answer is B
Explanation
Rationale:
A. This statement undermines the importance of therapeutic communication, which is essential in building trust and understanding with clients.
B. Therapeutic communication is indeed a fundamental part of mental health nursing and plays a crucial role in establishing a therapeutic relationship that supports the client's emotional and psychological well-being.
C. Therapeutic communication is vital in nurse-client interactions and is integral to effective mental health care, not just nurse-to-nurse communication.
D. Therapeutic communication in healthcare requires specific skills and approaches that differ from everyday conversation, emphasizing the need for sensitivity, empathy, and active listening.