When a patient states, "My son hasn't been to see me in months," the nurse's best verbal response is:
“Don't worry, I'm sure your son will visit."
"Your son hasn't been around much lately?"
"My son doesn't come to visit me either."
"How terrible that he doesn't visit you."
The Correct Answer is B
A. "Don't worry, I'm sure your son will visit."
This response is dismissive and assumes that the son will visit, which may not be the case. It may come across as insensitive.
B. "Your son hasn't been around much lately?"
This response reflects the patient's statement, encouraging them to elaborate. It shows empathy and gives the patient space to express their feelings.
C. "My son doesn't come to visit me either."
This response shifts focus away from the patient and may make them feel that their concern is trivialized.
D. "How terrible that he doesn't visit you."
This response is judgmental and might make the patient feel worse or lead them to think the nurse disapproves of their son.
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Correct Answer is C
Explanation
A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.
B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.
C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.
D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.
Correct Answer is B
Explanation
A. While elevated creatinine and BUN are important indicators of kidney function, in the diuretic phase, the focus shifts to monitoring for complications, particularly fluid and electrolyte balance.
B. Hypovolemia can occur due to excessive diuresis during the diuretic phase, which can lead to significant cardiovascular effects, including ECG changes related to electrolyte imbalances, particularly potassium levels.
C. Monitoring for uremic irritation is important but less critical than monitoring for hypovolemia and ECG changes that can lead to acute complications.
D. While monitoring for side effects of TPN is relevant, it is not the priority in the context of AKI transitioning phases where fluid and electrolyte balance are paramount.