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The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.

Select the 3 statements that the nurse should include when discussing caregiver stress with the client’s daughter.

You made a promise to your mother that you need to keep

Moving your mother into a care facility will show her that you do not love her

Helping your mother should be easier than raising a child

Involve your mother in the decision-making process

It is okay not to love or like your mother when you are caring for her

Take time for yourself and the other relationships that you care about

Answer and Explanation

Correct Answer : D,E,F

Choice D rationale
Involving the mother in the decision-making process can help alleviate some of the stress associated with caregiving. It allows the mother to maintain some control over her care and ensures that her needs and preferences are being met.
Choice E rationale
It is normal to have mixed feelings when caring for a loved one. Acknowledging these feelings can be an important part of managing caregiver stress.
Choice F rationale
Taking time for oneself and maintaining other relationships is crucial for caregiver well-being. It can help prevent burnout and improve the quality of care provided to the mother.

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Correct Answer is A

Explanation

Choice A rationale

Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.

Choice B rationale

While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.

Choice C rationale

Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.

Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.

Choice D rationale

Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.

A. Ventilation B. Neurological status C. Exposure D. Current medications E. Allergies F. Circulation

Correct Answer is ["A","B","C","F"]

Explanation

The correct answer is A. Ventilation, B. Neurological status, C. Exposure, F. Circulation.

Choice A: Ventilation Ventilation is a crucial part of the primary survey in trauma assessment. It involves assessing the patient’s respiratory rate and effort, use of accessory muscles, cyanosis, and chest wall movement. The normal respiratory rate for adults is between 12-20 breaths per minute.

Choice B: Neurological status Neurological status is another vital component of the primary survey. It often involves assessing the patient’s level of consciousness, often using tools like the Glasgow Coma Scale (GCS). The GCS score can range from 3 (completely unresponsive) to 15 (responsive).

Choice C: Exposure Exposure involves removing the patient’s clothing to check for any hidden injuries. It’s an essential step in trauma assessment, but there’s no “normal range” for this as it’s a process rather than a measurable variable.

Choice D: Current medications While knowing a patient’s current medications is important in managing their care, it’s not typically part of the primary survey in trauma assessment. This information is usually gathered during the secondary survey.

Choice E: Allergies Like current medications, information about allergies is also crucial in managing patient care, but it’s not part of the primary survey. This information is usually collected during the secondary survey.

Choice F: Circulation Circulation is a critical part of the primary survey. It involves checking the patient’s heart rate, blood pressure, capillary refill time, and looking for any signs of external bleeding. The normal resting heart rate can range between 60-99 beats per minute.

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The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct Answer is A

Explanation

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

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