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The client is now in less respiratory distress and is breathing at a rate of 40 breaths/minute. A transesophageal echocardiogram has been prescribed. The nurse recognizes that parents need extra support during invasive procedures.

For each intervention, click to indicate which intervention is suited to develop client trust for an infant or a toddler. Each row must have only one response option selected.

A.

Involve parents in procedure if desired.

B.

Designate one healthcare provider (HCP) to speak during procedure.

C.

Place familiar object with client if parents cannot be there.

D.

Prepare parents separately to avoid misinterpretation of words.

E.

Use firm and direct approach.

F.

Keep parents in line of vision.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}

  • Involve parents in procedure if desired (Infant): Infants rely on their parents for security and comfort; having parents present helps develop trust and reduces anxiety.
  • Designate one HCP to speak during procedure (Toddler): Toddlers benefit from clear, consistent communication; having one person give instructions helps reduce confusion and fosters trust.
  • Keep parents in line of vision (Infant): Seeing a familiar caregiver provides reassurance and emotional support for infants during procedures.
  • Place familiar object with client if parents cannot be there (Infant): Comfort items such as a blanket or toy help soothe infants and maintain a sense of security.
  • Prepare parents separately to avoid misinterpretation of words (Toddler): Toddlers can misinterpret explanations; preparing parents ensures they can support and accurately communicate with the child.
  • Use firm and direct approach (Toddler): Toddlers respond best to simple, direct instructions and boundaries to feel safe during procedures.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A,B,C"},"F":{"answers":"B"}}

Explanation

  • Weight gain: Indicates fluid retention (peripheral edema, pleural effusion), which is characteristic of heart failure.
  • Cardiac laboratory results: Markedly elevated BNP (806 pg/mL) is strongly indicative of heart failure. Troponin is within normal limits, making MI less likely.
  • Shortness of breath: Can occur in all three conditions—heart failure (fluid overload), pulmonary embolism (impaired perfusion), and myocardial infarction (decreased cardiac output).
  • Chest pain: Can be seen in both pulmonary embolism (often pleuritic) and myocardial infarction (pressure/heaviness).
  • Heart rate: Tachycardia is a nonspecific finding and can occur in all three conditions due to stress, hypoxia, or decreased cardiac output.
  • Chest x-ray results: Pleural effusion is most consistent with heart failure due to fluid accumulation.

Correct Answer is B

Explanation

A. Assessing the client for suicidal ideation is always an important safety measure when managing depression, particularly after changes in antidepressant therapy. However, in this scenario, the immediate priority is preventing a potentially dangerous drug interaction between duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), and phenelzine, a monoamine oxidase inhibitor (MAOI). Suicidal ideation assessment is ongoing but not the first critical action in this specific context.

B. Confirming the date the client last took duloxetine is correct. Phenelzine, an MAOI, has significant interactions with other antidepressants, particularly SNRIs like duloxetine. Administering phenelzine too soon after duloxetine can lead to serotonin syndrome, a potentially life-threatening condition characterized by agitation, confusion, hyperthermia, and autonomic instability. Confirming the last dose ensures an adequate washout period before initiating phenelzine and prevents dangerous interactions.

C. Evaluating if the client has taken phenelzine previously is useful for understanding past responses and tolerance, but it does not address the immediate safety concern related to drug interactions with the current therapy. This assessment is secondary to confirming the timing of the last duloxetine dose.

D. Reviewing the foods the client typically eats is important once the client is taking an MAOI because dietary tyramine restrictions are necessary to prevent hypertensive crises. However, this is not the immediate priority action at the time of medication change. Food restrictions should be addressed after confirming a safe transition period from duloxetine.

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