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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. Diabetes mellitus: An inverse association between diabetes mellitus (DM) and abdominal aortic aneurysm (AAA) risk hasbeen reported. Apart from a lower AAA prevalence among patients with vsthose without DM, there isdata showing that DM may exert a protective role on aneurysmal growth in patients with small AAAs, thus decreasing the risk of rupture. As atherosclerosis has almost the same risk factors as aneurysms, the decreased AAA prevalence in patients with DM may indicate that atherosclerosis is an associated feature and not a cause of the aneurysms.
B. Total cholesterol 170 mg/dL (less than 200 mg/dL): While elevated total cholesterol is a risk factor for cardiovascular disease, it is not specifically listed as a risk factor for abdominal aortic aneurysm (AAA). However, dyslipidemia, including elevated total cholesterol levels, can contribute to the development of atherosclerosis, which is a risk factor for AAA.
C. HDL cholesterol 65 mg/dL (male greater than 45 mg/dL; female greater than 55 mg/dL): High-density lipoprotein (HDL) cholesterol levels greater than 65 mg/dL are not listed as a risk factor for abdominal aortic aneurysm (AAA). However, low levels of HDL cholesterol are associated with an increased risk of cardiovascular disease, which may indirectly contribute to the development of AAA through the promotion of atherosclerosis.
D. Smoking cigarettes: Smoking cigarettes is a significant modifiable risk factor for abdominal aortic aneurysm (AAA). Smoking damages the walls of blood vessels, promotes inflammation, and accelerates the development of atherosclerosis, increasing the risk of AAA formation and rupture.
E. Family history of aneurysm: A family history of aneurysm, particularly abdominal aortic aneurysm (AAA), is a risk factor for developing AAA. Genetic factors can predispose individuals to the development of aneurysms, and a positive family history increases the likelihood of AAA occurrence.
Correct Answer is A
Explanation
A. Loss of sensation and cognition difficulties: Secondary conditions commonly associated with traumatic brain injury (TBI) include sensory impairments such as loss of sensation, as well as cognitive difficulties such as memory loss, attention deficits, and impaired executive functioning. These issues arise due to the damage to brain tissue caused by the initial injury and can have significant impacts on the client's overall function and quality of life.
B. Development of emotional disorders and acute pain : While emotional disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD) are common following TBI, acute pain is not typically considered a primary secondary condition associated with TBI. Chronic pain may develop as a secondary condition, but acute pain is more often associated with the immediate aftermath of the injury.
C. Body dysmorphia and neurofibrillary tangles : Body dysmorphia, a condition characterized by obsessive preoccupation with perceived flaws in physical appearance, and neurofibrillary tangles, abnormal protein aggregates found in the brains of individuals with neurodegenerative disorders such as Alzheimer's disease, are not typically associated with TBI.
D. Decreased appetite and a lack of sleep : While changes in appetite and sleep disturbances may occur as secondary symptoms of TBI, they are not as commonly anticipated as loss of sensation and cognition difficulties. These issues may arise due to disruptions in brain function or changes in lifestyle following the injury.
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