A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?
Vomiting
Urticaria
Low back pain
Pulmonary congestion
The Correct Answer is C
Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.
Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.
Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.
Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Conversion typically refers to the expression of psychological distress through physical symptoms, which is not the case here.
Choice B reason: Undoing is a defense mechanism where a person tries to 'undo' an unhealthy thought or behavior with a healthier one, which does not apply to Michael's situation.
Choice C reason: Compensation is a defense mechanism where a person overachieves in one area to make up for deficiencies in another, which describes Michael's actions.
Choice D reason: Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not explicitly indicated in this scenario.
Correct Answer is A
Explanation
Choice A reason: Patients with Personality Disorders often struggle with maladaptive behaviors. A general goal is to help them find nondestructive ways to fulfill their needs, promoting healthier interactions and coping mechanisms.
Choice B reason: While establishing relationships is important, the priority is to ensure that the patient's methods of interacting are healthy and nondestructive.
Choice C reason: Understanding the impact of one's behavior on others is a goal, but it is secondary to the patient learning nondestructive self-management skills.
Choice D reason: Employment is a long-term goal and, while important, it is not as immediately relevant to the therapeutic process as developing nondestructive behaviors.
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