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","C","E"]
Explanation
Rationale:
A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.
B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.
C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.
D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.
E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.