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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 C

Explanation

A) Computed tomography (CT) scan: A CT scan may provide detailed images of the heart and surrounding structures, but it is not typically the initial diagnostic test used to assess for cardiac tamponade. CT scans are often used in conjunction with other diagnostic tests but are not the first-line investigation for suspected tamponade.

B) Chest x-ray: While a chest x-ray may show signs of cardiac tamponade, such as an enlarged cardiac silhouette or evidence of fluid accumulation around the heart, it is not as sensitive or specific as other diagnostic tests, particularly in the acute setting. Chest x-rays may be obtained as part of the diagnostic workup, but they are not the first-line test for suspected tamponade.

C) Echocardiogram: An echocardiogram is the most appropriate initial diagnostic test for suspected cardiac tamponade. It provides real-time imaging of the heart and can detect pericardial effusion, collapse of the right atrium and ventricle during diastole (diastolic collapse), and signs of hemodynamic compromise. Echocardiography allows for rapid assessment at the bedside and can guide immediate management decisions.

D) Electrocardiogram (ECG): While an electrocardiogram may show nonspecific changes in cardiac tamponade, such as low-voltage QRS complexes or electrical alternans, it is not as sensitive or specific as an echocardiogram for diagnosing tamponade. ECG findings may support the diagnosis but are not typically the first-line test for suspected tamponade.

A. Consume foods high in potassium B. Increase oral intake of water C. Avoid smoking tobacco products D. Limit alcohol to two drinks daily

Correct Answer is C

Explanation

A. Consume foods high in potassium: Potassium deficiency can contribute to certain health issues, but it is not directly linked to hearing loss. However, maintaining a balanced diet rich in nutrients, including potassium, is important for overall health.

B. Increase oral intake of water: Hydration is essential for overall health, but increasing oral intake of water is not specifically associated with decreasing the risk of hearing loss. While staying hydrated is beneficial for various bodily functions, including maintaining proper ear function, it is not a direct preventive measure for hearing loss.

C. Avoid smoking tobacco products: Smoking tobacco products is a significant risk factor for developing hearing loss. Smoking can damage blood vessels and reduce blood flow to the inner ear, leading to hearing impairment. Therefore, advising clients to avoid smoking or quit smoking is an important lifestyle modification to decrease the risk of hearing loss.

D. Limit alcohol to two drinks daily: Excessive alcohol consumption can have detrimental effects on hearing health, including increasing the risk of hearing loss and vestibular dysfunction. Therefore, limiting alcohol intake is recommended to reduce the risk of developing hearing-related problems.

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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:

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