A nurse is educating a client about possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?
"My elevated heart rate could be the cause of my depressed mood."
"My renal dysfunction could be the cause of my depressed mood."
"My high blood pressure could be the cause of my depressed mood."
"The stress from my new job could be the cause of my depressed mood."
The Correct Answer is D
Rationale:
A. An elevated heart rate alone is not commonly associated with depression.
B. While renal dysfunction can impact mood, the direct link between it and depression is not as strong as other factors.
C. High blood pressure is not a direct cause of depression, though it can contribute to overall health issues.
D. Stress from a new job is a common and recognizable factor that can lead to or exacerbate depressive symptoms, showing an understanding of how situational stress can impact mood.
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Correct Answer is D
Explanation
Rationale:
A. The medication administration record is important for verifying the order but should be used in conjunction with the patient’s identification.
B. The order sheet provides the details of the blood product to be administered but is not the primary source for verifying patient identity.
C. The chart includes medical history and orders but does not provide direct patient identification for blood administration.
D. The identification wristband is the primary and most direct method for verifying the patient’s identity to ensure that the correct blood product is administered to the correct patient.
Correct Answer is C
Explanation
Rationale:
A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.
B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.
C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.
D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.