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A nurse is providing care for a client who has multiple organ dysfunction syndrome (MODS). Which of the following actions is the priority when planning care for this client?

Ensuring that the client and their family are kept informed about the client's care

Being aware of the client's wishes regarding care

Scheduling periods of rest for the client

Discussing the client's resting times with the family

None

Answer and Explanation

The Correct Answer is A

Answer: A. Ensuring that the client and their family are kept informed about the client's care

Rationale:

A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.

B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.

C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.

D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.

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Correct Answer is A

Explanation

A. "A deregulated cytokine storm causes an inflammatory response": Systemic inflammatory response syndrome (SIRS) is characterized by a dysregulated inflammatory response triggered by various insults such as infection, trauma, burns, or ischemia. In SIRS, the immune system responds excessively, leading to the release of pro-inflammatory cytokines (cytokine storm), including tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6). This cytokine cascade results in widespread inflammation and systemic manifestations, such as fever, tachycardia, tachypnea, and leukocytosis.

B. "The major organ prone to injury during SIRS is the heart": While SIRS can lead to multi-organ dysfunction, including cardiac dysfunction, it does not primarily target the heart. SIRS affects multiple organs, including the lungs, kidneys, liver, and gastrointestinal tract. Cardiac dysfunction in SIRS may result from the inflammatory response, hypoperfusion, or direct myocardial injury.

C. "Spleen dysfunction causes blood clotting issues": SIRS can lead to coagulation abnormalities, but spleen dysfunction is not the primary cause. Coagulation abnormalities in SIRS are often attributed to endothelial dysfunction, activation of the coagulation cascade, and consumption of clotting factors, rather than spleen dysfunction.

D. "Activation of the inflammatory cascade causes increased perfusion": Activation of the inflammatory cascade in SIRS does not typically lead to increased perfusion. Instead, SIRS can lead to alterations in perfusion, including tissue hypoperfusion and microvascular dysfunction. In severe cases, SIRS can progress to septic shock, characterized by profound hypotension and inadequate tissue perfusion.

A. Colchicine B. Acetaminophen C. Indomethacin D. Amiodarone E. Nitroglycerine

Correct Answer is ["A","C"]

Explanation

A. Colchicine:

Colchicine is commonly used in the treatment of pericarditis, especially in cases of recurrent or refractory pericarditis.

It helps reduce inflammation and alleviate symptoms by inhibiting the migration of neutrophils to the inflamed pericardium.

Colchicine is often used in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids for the management of pericarditis.

B. Acetaminophen:

Acetaminophen is a pain reliever and fever reducer commonly used to manage mild to moderate pain associated with various conditions, including pericarditis.

While acetaminophen may provide symptomatic relief, it is not typically considered a primary treatment for pericarditis, especially in cases of severe or recurrent pericarditis.

C. Indomethacin:

Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain associated with pericarditis.

NSAIDs are often used as first-line therapy for acute pericarditis to alleviate symptoms such as chest pain and fever.

However, caution should be exercised when using NSAIDs in certain populations, such as older adults or those with preexisting gastrointestinal or renal conditions.

D. Amiodarone:

Amiodarone is an antiarrhythmic medication used to treat various types of arrhythmias, including ventricular arrhythmias and atrial fibrillation.

While pericarditis may lead to certain arrhythmias, such as atrial fibrillation, amiodarone is not a first-line treatment for pericarditis itself.

However, it may be used in cases where pericarditis is complicated by arrhythmias or concomitant cardiac conditions.

E. Nitroglycerine:

Nitroglycerine is a vasodilator medication commonly used to treat angina and heart failure.

While pericarditis may cause chest pain similar to angina, nitroglycerine is not typically used as a primary treatment for pericarditis.

In fact, nitroglycerine may exacerbate symptoms of pericarditis by causing venodilation and increasing cardiac preload.

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A nurse is providing care for a client who has multiple organ dysfunction syndrome (MODS). Which of the following actions is the priority when planning care for this client?

Rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","C"]

Explanation

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