Choice A Reason:

Planning to remove the restraints as soon as the client is calm is a correct action. Restraints should be used for the shortest duration necessary to ensure safety. Once the client is calm and no longer poses a risk to themselves or others, the restraints should be removed promptly.

Choice B Reason:

Ensuring that the provider has signed a prescription for restraints within 48 hr is incorrect. Restraints should never be applied without a proper prescription or order from a qualified healthcare provider. The provider's order should be obtained before applying restraints, not within 48 hours afterward.

Choice C Reason:

Offering the client, a nutritious snack every 4 hr is unrelated to the use of physical restraints and should not be the nurse's priority in this situation. The focus should be on ensuring the client's safety and addressing their behavior.

Choice D Reason:

Monitoring the client's range of motion every 60 min is a correct action. When a client is restrained, it's essential to monitor their physical well-being regularly. Monitoring range of motion helps ensure that the restraints are not causing harm or discomfort to the client. The specific time interval for monitoring may vary by facility policy but should be frequent enough to assess the client's condition effectively.

Choice A Reason:

"I might have occasional seizures for several days after the procedure." This statement is not accurate. ECT does induce a controlled seizure during the procedure, but clients typically do not experience seizures after the treatment. This statement does not indicate an understanding of the procedure.

Choice B Reason:

"I might have short-term memory loss after the procedure. “This statement is accurate. Memory loss is a common side effect of ECT, particularly short-term memory loss. It's important for the client to be aware of this potential side effect.

Choice C Reason:

"I will have a urinary catheter in place during the procedure." This statement is not accurate. A urinary catheter is not typically used during ECT. It's important for the client to have accurate information about the procedure.

Choice D Reason:

"I will need to follow a full-liquid diet for 24 hours after the procedure." This statement is not accurate. Clients undergoing ECT do not usually require a full-liquid diet afterward. The dietary restrictions may vary depending on the facility's policies, but it is not typically a full-liquid diet.

Choice A Reason:

Maintaining the client in high-Fowler's position is a correct action. Keeping the client in a high-Fowler's position (sitting up with the head of the bed elevated) can help improve lung expansion and ease breathing for clients with heart failure and respiratory distress.

Choice B Reason:

Instructing the client to cough every 4 hr. is not directly addressing the underlying issue of fluid accumulation and respiratory distress associated with heart failure. Coughing alone may not be sufficient to alleviate these symptoms.

Choice C Reason:

Increasing the client's intake of oral fluids is generally not recommended without considering the client's overall fluid status. In heart failure, there is often a need to restrict fluid intake to prevent fluid overload and worsening of symptoms. Increasing oral fluids should be done cautiously and under the guidance of the healthcare provider.

Choice D Reason:

Encouraging the client to ambulate to loosen secretions. While ambulation can be beneficial for some clients to improve overall circulation and prevent complications, it may not be the primary intervention in this case. The client's primary issue is likely related to pulmonary congestion due to heart failure, and they may be too short of breath to ambulate effectively.

Choice A Reason:

"This medication prevents your baby from developing bleeding problems." This is the correct statement. Phytonadione is given to newborns to prevent neonatal vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including intracranial hemorrhage.

Choice B Reason:

"This medication enhances regulation of your baby's temperature." Phytonadione does not have any direct impact on the regulation of a baby's temperature. Its primary purpose is to prevent bleeding issues.

Choice C Reason:

"This medication enhances your baby's immune response. Phytonadione does not enhance a baby's immune response. It primarily addresses vitamin K deficiency and associated bleeding risks.

Choice D Reason:

"This medication prevents your baby from developing jaundice." Phytonadione is not used to prevent jaundice. Jaundice is typically related to bilirubin levels and is managed separately from vitamin K supplementation.

Choice A Reason:

Improved respiratory function is incorrect. Pancrelipase primarily helps with the digestion and absorption of fats and fat-soluble vitamins. It does not directly impact respiratory function. Respiratory improvement in cystic fibrosis typically involves treatments such as airway clearance techniques, bronchodilators, and antibiotics to manage lung infections.

Choice B Reason:

Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy used to treat individuals with cystic fibrosis, a condition that affects the pancreas's ability to produce digestive enzymes. Cystic fibrosis leads to the malabsorption of nutrients, especially fats. Pancrelipase supplements these digestive enzymes and helps the child digest and absorb fat properly. As a result, one of the expected therapeutic effects of pancrelipase is a reduction in fat in the stools, as the enzymes aid in the digestion of dietary fats, leading to improved absorption of nutrients. This, in turn, can help address malnutrition and promote overall health in individuals with cystic fibrosis.

Choice C Reason:

Improved absorption of vitamins B and C is incorrect. While pancrelipase can help with the absorption of fat-soluble vitamins (A, D, E, and K), it does not directly affect the absorption of vitamins B and C, which are water-soluble vitamins. Cystic fibrosis primarily affects the absorption of fat-soluble vitamins due to impaired fat digestion.

Choice D Reason:

Decreased sodium excretion is incorrect. Cystic fibrosis is associated with excessive loss of salt (sodium chloride) in sweat. Pancrelipase does not directly affect sodium excretion. Treatment for managing sodium loss typically involves salt supplementation and ensuring proper hydration.

Choice A Reason:

Supine is incorrect. The supine position (lying flat on the back) is not the best choice because it can increase the risk of airway obstruction and discomfort, especially if there is swelling or drainage from the surgical site.

Choice B Reason:

Left lateral is incorrect. The left lateral position (lying on the left side) is not typically used after a thyroidectomy because it does not provide the same advantages for airway management, swelling reduction, and comfort as the semi-Fowler's position.

Choice C Raeson:

Semi-Fowler's position is the most appropriate choice for a client who is postoperative following a subtotal thyroidectomy for several reasons:

Airway Management: Elevating the head of the bed in a semi-Fowler's position helps maintain airway patency and reduces the risk of airway obstruction or compression of the surgical site, which is important for respiratory comfort and function.

Swelling and Drainage: After thyroid surgery, there may be swelling and drainage from the surgical site. The semi-Fowler's position can assist in reducing swelling and facilitating proper drainage.

Comfort: This position generally provides greater comfort for the client, especially when there may be discomfort or soreness at the surgical site.

Choice D Reason:

Dorsal recumbent is incorrect. The dorsal recumbent position (lying on the back with knees flexed and feet flat on the bed) is also not the most appropriate choice for post-thyroidectomy care because it does not offer the same benefits as the semi-Fowler's position in terms of airway management, swelling reduction, and comfort.

Choice A Reason:

Loose stools are not a typical side effect of radiation therapy for throat cancer. Gastrointestinal side effects may occur, but they are more likely to involve symptoms such as nausea, diarrhea, or difficulty swallowing.

Choice B Reason:

Bladder infection is not directly related to radiation therapy for throat cancer. The side effects of radiation therapy typically pertain to the area being treated, such as the throat and surrounding tissues.

Choice C Reason:

Increased appetite is also not a common side effect of radiation therapy. Many clients may experience a decreased appetite or difficulty eating due to the side effects of radiation, such as mucositis (inflammation of the mouth and throat) or dysgeusia.

Choice D Reason:

Loss of taste is correct . Clients who receive external radiation therapy for throat cancer can experience various side effects due to the radiation's impact on the surrounding tissues. One common side effect is a loss of taste or changes in taste perception, which is known as dysgeusia. This occurs because radiation can damage taste buds and the salivary glands, leading to alterations in taste sensation. Clients may describe a metallic or bitter taste in their mouths or have difficulty tasting certain foods.

Choice A Reason:

Clammy skin is incorrect. DKA is more likely to cause dry or flushed skin due to dehydration and the effects of high blood sugar levels. Clammy skin is usually associated with conditions that cause excessive sweating.

Choice B Reason:

Bounding pulse is incorrect. DKA can lead to tachycardia (a rapid heart rate) as the body tries to compensate for the metabolic imbalances, but a bounding pulse is not a characteristic finding of DKA.

Choice C Reason:

Elevated blood pressure is incorrect. DKA is more likely to result in an initial decrease in blood pressure due to dehydration. Elevated blood pressure may be present in other conditions but is not a primary feature of DKA.

Choice D Reason:

Fruity breath odor is correct. Diabetic ketoacidosis (DKA) is a serious complication of diabetes characterized by a buildup of ketones in the blood, which results from the body breaking down fat for energy due to a lack of insulin. Fruity breath odor, often described as smelling like acetone or nail polish remover, is a classic sign of DKA. It occurs because the presence of ketones in the blood leads to the exhalation of acetone through the breath.

Choice A Reason:

Restraining the child's upper extremities is not recommended. It's important to allow the child to move freely during the seizure to prevent injury. Attempting to restrain their movements could result in harm to the child or the person attempting to restrain them.

Choice B Reason:

Turning the child onto their back is generally appropriate as long as you do it gently and without force. It helps ensure that the airway remains clear and allows any fluids to drain out of the mouth. However, you should not forcibly turn the child; instead, gently guide them if necessary.

Choice C Reason:

Placing a padded tongue blade or any object in the child's mouth is strongly discouraged during a seizure. Doing so can result in injury to the child's mouth, teeth, or jaw. It is a common misconception that someone might swallow their tongue during a seizure, but this rarely happens. It's essential to keep the child's airway clear but not to insert any objects into their mouth.

D. Placing a pillow under the child's head is appropriate to protect their head from injury, especially if they are on a hard surface. It can help cushion the head and reduce the risk of head trauma during the seizure.