NCLEX- RN Practice Exam 6

EXPLANATION

✔Correct answers:

Listening to lung sounds. Listening to lung sounds is essential in assessing a patient with symptoms of a cold, persistent cough, and lung congestion. This helps in identifying abnormal breath sounds such as crackles, wheezes, or rhonchi, which can provide clues about respiratory infections, pneumonia, or other pulmonary conditions.

Measuring the client’s temperature. Measuring the client’s temperature is crucial to determine if there is an underlying infection causing the symptoms. Fever can indicate the presence of an upper respiratory infection or pneumonia.

Gathering information about the client’s respirations. Assessing the client's respiratory rate, rhythm, and effort is important to evaluate respiratory function and identify any signs of respiratory distress or hypoxia.

✘Incorrect answer options:

Assessing the strength of peripheral pulses This action is more relevant to cardiovascular assessments and is not directly related to the client’s symptoms of a cold, persistent cough, and lung congestion.

Conducting a musculoskeletal and neurological exam While comprehensive assessments are important, a focused data collection for respiratory symptoms does not typically include a detailed musculoskeletal and neurological exam unless indicated by other presenting symptoms.

Inquiring about the client’s family history of illnesses or diseases Although family history is valuable in a comprehensive health assessment, it is not a priority in the focused data collection for symptoms of a cold, persistent cough, and lung congestion.

EXPLANATION

✔Correct answer:

Demeclocycline. Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition where excessive antidiuretic hormone (ADH) is released, leading to water retention, hyponatremia (low sodium levels), and hypo-osmolality. In patients with lung carcinoma, SIADH can occur as a paraneoplastic syndrome where the tumor cells produce ADH or ADH-like substances. Demeclocycline, an antibiotic, is often prescribed because it reduces the kidney's response to ADH, thereby increasing water excretion and correcting hyponatremia.

In SIADH, the excess ADH causes the kidneys to reabsorb more water, diluting the blood and leading to low sodium levels. Demeclocycline interferes with the action of ADH on the renal tubules, promoting water excretion and increasing serum sodium levels.

Imagine a sponge (the kidneys) being constantly soaked with water (ADH). Normally, the sponge would release excess water, but in SIADH, the sponge holds onto the water. Demeclocycline acts like a wringer that helps squeeze out the excess water, restoring balance.

Nurses should monitor the patient's fluid balance, serum sodium levels, and overall response to demeclocycline therapy.

• Monitor intake and output to ensure effective fluid balance management.
• Regularly check serum sodium levels to track improvement in hyponatremia.
• Assess for signs and symptoms of electrolyte imbalances and dehydration.
• Educate the patient about the importance of adhering to the prescribed treatment and dietary restrictions.

✘Incorrect answer options:

Increased fluid intake This would exacerbate the condition by further diluting the serum sodium levels and worsening hyponatremia. In SIADH, fluid restriction is often recommended to help manage water retention and increase sodium concentration.

Desmopressin This is a synthetic form of ADH used to treat diabetes insipidus and conditions characterized by ADH deficiency. It would be contraindicated in SIADH because it would worsen the condition by increasing water retention.

Potassium supplements While maintaining electrolyte balance is important, potassium supplementation is not a primary treatment for SIADH. The focus in SIADH is on managing water retention and correcting hyponatremia, not potassium levels.

EXPLANATION

✔Correct answers:

Radiation therapy and Chemotherapy treatment. Radiation therapy and chemotherapy are treatments aimed at reducing the size of the lung carcinoma, which can help in alleviating the paraneoplastic syndrome of SIADH by decreasing the tumor's production of ADH or ADH-like substances.

Monitoring serum sodium levels. Regular monitoring of serum sodium levels is crucial in managing SIADH, as it helps to assess the effectiveness of treatments and guide adjustments in therapy to prevent or address hyponatremia.

Administering medication that opposes antidiuretic hormone (ADH). Medications such as demeclocycline or vasopressin receptor antagonists (e.g., tolvaptan) can be prescribed to reduce the effects of ADH on the kidneys, promoting water excretion and helping to correct hyponatremia.

SIADH results from excessive release of ADH, leading to water retention and dilutional hyponatremia. Effective management involves addressing the underlying cause (lung carcinoma) and managing the symptoms related to water imbalance and hyponatremia.

Imagine a sponge (the kidneys) constantly soaking up water (due to excessive ADH). Treatments like radiation and chemotherapy aim to shrink the source of water (the tumor), while medications that oppose ADH and monitoring sodium levels ensure the sponge doesn’t hold too much water, preventing overflow (hyponatremia).

Nurses play a critical role in monitoring and managing patients with SIADH by closely tracking fluid intake, serum sodium levels, and the patient's response to treatment.

• Monitor intake and output to maintain fluid balance and prevent fluid overload.
• Regularly check serum sodium levels to guide treatment adjustments and ensure patient safety.
• Administer medications as prescribed and educate the patient about their purpose and potential side effects.
• Collaborate with the healthcare team to adjust treatment plans based on the patient's progress and response to therapy.

✘Incorrect answer options:

Increasing fluid intake This would exacerbate the condition by increasing water retention and worsening hyponatremia. Instead, fluid restriction is typically recommended to manage SIADH.

Reducing oral sodium consumption Reducing sodium intake would further lower serum sodium levels, worsening hyponatremia. In SIADH, maintaining or even slightly increasing sodium intake may be necessary to help correct the sodium imbalance.

EXPLANATION

✔Correct answer:

Gingival hyperplasia and nystagmus. Phenytoin (Dilantin) is an anticonvulsant medication commonly used to manage and prevent seizures. Among its known side effects, gingival hyperplasia (overgrowth of gum tissue) and nystagmus (involuntary eye movements) are particularly significant. Gingival hyperplasia is a common chronic side effect seen in long-term phenytoin use, often requiring dental care to manage. Nystagmus, on the other hand, can occur at therapeutic or toxic levels of phenytoin and is indicative of its effects on the central nervous system.

Phenytoin stabilizes neuronal membranes and decreases seizure activity by reducing the spread of seizure discharges. However, its impact on cellular functions can lead to overgrowth of the gums and affect ocular muscles, causing nystagmus.

Imagine using a powerful weed killer in a garden to control unwanted plants (seizures). While it effectively prevents the growth of weeds, it might also cause unintended side effects on the flowers and other plants (gums and eye muscles), leading to overgrowth and unusual movement.

Nurses should monitor clients on phenytoin for these side effects and provide appropriate interventions to manage and mitigate them.

• Conduct regular oral examinations and encourage good oral hygiene practices to prevent and manage gingival hyperplasia.
• Monitor for signs of nystagmus, such as involuntary eye movements or difficulty focusing, and report these findings to the healthcare provider.
• Educate clients about the importance of dental care and regular check-ups to manage gingival hyperplasia.
• Ensure therapeutic drug monitoring of phenytoin levels to avoid toxicity and minimize side effects.

✘Incorrect answer options:

Hypotension and bradycardia These symptoms are not typically associated with phenytoin. Hypotension and bradycardia are more commonly seen with medications that affect cardiac function, such as beta-blockers or calcium channel blockers.

Increased urine output and thirst These symptoms are indicative of conditions like diabetes mellitus or diabetes insipidus, not phenytoin use. Phenytoin does not typically cause increased urine output or excessive thirst.

Diarrhea and abdominal cramping While gastrointestinal side effects can occur with many medications, they are not the most characteristic or notable side effects of phenytoin. Gingival hyperplasia and nystagmus are more specific to phenytoin.

EXPLANATION

✔Correct answer:

"You'll need to lie flat for a few hours after the procedure to prevent headaches." After a myelogram, it is common for patients to be instructed to lie flat for several hours. This recommendation helps to prevent headaches, which can occur if cerebrospinal fluid (CSF) leaks from the puncture site. Lying flat helps maintain even pressure in the spinal canal, reducing the likelihood of post-procedural headaches caused by CSF leakage.

A myelogram involves injecting contrast dye into the spinal canal, which enhances imaging of the spinal cord and nerves during X-ray or CT scan. The procedure requires a lumbar puncture, which can create a potential pathway for CSF to escape, leading to a decrease in CSF pressure. This decrease can cause a spinal headache, characterized by pain that worsens when upright and improves when lying down.

Imagine a balloon filled with water (representing the spinal canal with CSF). If you poke a hole in the balloon, water starts to leak out (CSF leakage). Keeping the balloon flat can slow down or stop the leak, preventing it from losing too much water too quickly (reducing headache risk).

Nurses should ensure the patient follows post-procedure instructions to lie flat, monitor for headache symptoms, and provide appropriate care if a headache develops.

• Explain to the patient the importance of lying flat to minimize the risk of headaches.
• Monitor the patient's vital signs and neurological status post-procedure.
• Encourage the patient to report any symptoms of headache, nausea, or dizziness.
• Provide fluids and pain relief as prescribed to support recovery and comfort.

✘Incorrect answer options:

"You should avoid eating and drinking for 12 hours before the procedure." Typically, fasting for a myelogram is not required for such an extended period. The fasting period may vary, but it is generally shorter, often 4-6 hours before the procedure. This recommendation is more relevant to other diagnostic tests or surgeries requiring general anesthesia.

"You can resume normal activities immediately after the procedure." This is incorrect because patients are usually advised to take it easy for the rest of the day and avoid strenuous activities for at least 24 hours after a myelogram to prevent complications such as headaches or discomfort at the puncture site.

"It's important to drink plenty of fluids before the procedure to stay hydrated." While staying hydrated is generally good advice, it is not specifically emphasized before a myelogram. Post-procedure hydration is often recommended to help flush out the contrast dye used during the procedure, but excessive fluid intake before the procedure is not typically required.

EXPLANATION

✔Correct answer:

31 drops per minute. To determine the IV flow rate in drops per minute, Nurse Jessica should use the following formula:

Flow rate (gtt/min) = (Total volume (ml) / Total time (min)) × Drop factor (gtt/ml)

Given:

- Total volume = 3,000 ml

- Total time = 24 hours (which is 24 × 60 minutes = 1,440 minutes)

- Drop factor = 15 drops/ml

Now, applying the values to the formula:

Flow rate (gtt/min) = (3,000 ml / 1,440 min) × 15 gtt/ml

Flow rate (gtt/min) = (3,000 / 1,440) × 15

Flow rate (gtt/min) = 2.083 × 15

Flow rate (gtt/min) = 31.25

Rounding to the nearest whole number, the IV flow rate is 31 drops per minute.

Imagine you need to fill a large water tank using a hose that releases a certain number of drops per minute. To fill the tank within a specific time, you calculate how many drops per minute are required by considering the total volume of the tank and the total time available.

✘Incorrect answer options:

15 drops per minute: This rate would be too low and would not deliver the required 3,000 ml in 24 hours.

21 drops per minute: This rate is also too low and would not deliver the required volume within the specified time.

42 drops per minute: This rate is too high and would deliver more than the required volume in the given time, leading to potential fluid overload.

EXPLANATION

✔Correct answer:

Induce asystole so the heart's natural pacemaker can regain control.  The primary purpose of defibrillation is to deliver a controlled electrical shock to the heart to stop the chaotic electrical activity associated with ventricular fibrillation. This shock temporarily stops all electrical activity in the heart, including the abnormal rhythms (inducing a momentary asystole), allowing the heart's natural pacemaker (the sinoatrial node) to reset and re-establish a normal rhythm.

Ventricular fibrillation (VF) is a life-threatening cardiac arrhythmia characterized by rapid, erratic electrical impulses in the ventricles. This erratic activity prevents the heart from effectively pumping blood, leading to a sudden drop in cardiac output and, if not corrected, can result in death. Defibrillation interrupts the disorganized electrical activity, giving the heart a chance to restart its normal rhythm.

Imagine a malfunctioning computer that needs to be rebooted. Defibrillation acts like pressing the reset button, turning the computer (heart) off briefly to clear the errors (abnormal rhythms) and allowing it to restart correctly.

After defibrillation, Nurse Sarah should:

• Monitor the patient's heart rhythm closely to assess for the return of normal sinus rhythm.
• Check the patient's vital signs frequently, including blood pressure and oxygen saturation.
• Assess the patient for any injuries or burns at the defibrillation pad sites.
• Provide emotional support and reassurance to the patient and family members.
• Document the event, including the time of defibrillation, energy level used, and the patient's response.

✘Incorrect answer options:

Enhance cardiac contractility and increase cardiac output. While defibrillation aims to restore normal heart rhythm, it does not directly enhance cardiac contractility or increase cardiac output. These effects are secondary outcomes of restoring a normal, coordinated heart rhythm.

Decrease cardiac ischemia and reduce acidosis. Defibrillation does not directly address cardiac ischemia (reduced blood flow to the heart) or acidosis (acid buildup in the blood). These conditions may improve indirectly if normal cardiac rhythm and function are restored, but they are not the primary targets of defibrillation.

Supply energy to the depleted myocardial cells. Defibrillation delivers an electrical shock to reset the heart's electrical activity but does not provide energy to myocardial cells in the form of nutrients or oxygen. It aims to correct the electrical dysfunction rather than supply metabolic energy.

EXPLANATION

✔Correct answer:

A non-hairy area. To enhance the percutaneous absorption of nitroglycerine ointment, Nurse Emily should choose a non-hairy area. Hair can act as a barrier and impede the direct contact of the ointment with the skin, reducing absorption. Selecting a non-hairy area ensures that the medication can be absorbed more efficiently through the skin.

Nitroglycerine is a vasodilator used to treat angina by relaxing blood vessels and improving blood flow to the heart. When applied as an ointment, it is absorbed through the skin into the bloodstream. The rate and extent of absorption can be influenced by the condition of the skin and the area of application. Non-hairy areas offer less resistance and allow for better contact and absorption.

Imagine you are trying to paint a smooth surface versus a textured surface. The smooth surface (non-hairy skin) allows the paint (ointment) to spread evenly and be absorbed better, whereas the textured surface (hairy skin) prevents even application and absorption.

When applying nitroglycerine ointment, Nurse Emily should:

• Choose an area with minimal or no hair to ensure optimal absorption.
• Ensure the skin is clean and dry before application.
• Rotate application sites to prevent skin irritation.
• Wear gloves to avoid self-absorption of the medication.
• Instruct the patient not to rub or massage the area to prevent rapid absorption and potential side effects.

✘Incorrect answer options:

A muscular area. While muscular areas might have good blood flow, they are not necessarily the best for ointment absorption. The presence of hair or the thickness of the muscle does not specifically enhance percutaneous absorption compared to a non-hairy area.

A location close to the heart. The proximity to the heart is not a factor in enhancing the absorption of topical ointments. The absorption depends on the condition and type of skin, not the anatomical location in relation to the heart.

Over a bony prominence. Bony prominences are not ideal for ointment application because the skin over these areas is often thinner and can be more prone to irritation or damage. Additionally, they do not provide the best surface for absorption compared to non-hairy, fleshy areas.

EXPLANATION

✔Correct answer:

Risk for injury. The best nursing diagnosis for a 23-year-old man with acute lymphocytic leukemia (ALL) and thrombocytopenia (low platelet count) is "Risk for injury." Thrombocytopenia significantly increases the risk of bleeding and bruising due to a reduced number of platelets, which are essential for blood clotting. In the context of ALL, the patient's bone marrow is not producing enough normal blood cells, including platelets, increasing the likelihood of spontaneous bleeding and bruising, as observed in his physical exam.

Acute lymphocytic leukemia is a type of cancer where the bone marrow makes too many immature lymphocytes (a type of white blood cell). This abnormal production interferes with the production of other essential blood components, such as red blood cells and platelets, leading to symptoms like fatigue, pallor, and an increased tendency to bruise or bleed (thrombocytopenia).

Imagine your blood clotting system as a team of construction workers who repair any damage to a building (your blood vessels). If the team is short-staffed (thrombocytopenia), it takes longer to repair any damage, resulting in more visible cracks and damage (bruises and bleeding).

Nurses should focus on minimizing the patient's risk of injury by implementing safety measures and monitoring for signs of bleeding.

• Educate the patient on avoiding activities that could lead to cuts or bruises.
• Inspect the patient's skin daily for new bruises or petechiae.
• Monitor laboratory values closely, including platelet counts and coagulation profiles.
• Administer prescribed platelet transfusions as necessary.
• Encourage the use of a soft toothbrush and electric razor to prevent bleeding from gums or cuts.
• Implement fall precautions, such as using non-slip footwear and ensuring the environment is free of hazards.

✘Incorrect answer options:

Self-care deficit. While the patient may experience fatigue and weakness, leading to challenges in self-care, this diagnosis does not directly address the critical issue of thrombocytopenia and the associated risk of bleeding and injury.

Risk for self-harm. This diagnosis is more relevant for patients exhibiting behaviors or thoughts of intentional self-injury or suicide. There is no indication in the scenario that the patient is at risk for self-harm.

Altered comfort. Although the patient might experience discomfort due to symptoms of leukemia, such as fatigue and bruising, this diagnosis does not capture the urgent need to prevent injury due to thrombocytopenia.

EXPLANATION

✔Correct answer:

Blood urea nitrogen (BUN) and creatinine levels. Gentamicin (Garamycin) is an aminoglycoside antibiotic that is primarily excreted by the kidneys. It is known for its nephrotoxic potential, meaning it can cause damage to the kidneys. Therefore, it is crucial to monitor renal function closely when a patient is on this medication. Blood urea nitrogen (BUN) and creatinine levels are key indicators of kidney function. Elevated levels can signify renal impairment, which is a significant concern with gentamicin therapy.

Gentamicin can accumulate in the renal cortex, leading to nephrotoxicity by causing tubular necrosis. This results in decreased kidney function and the subsequent increase of BUN and creatinine levels in the blood. Regular monitoring of these values helps in early detection of nephrotoxicity, allowing for timely intervention to prevent further kidney damage.

Think of the kidneys as a coffee filter that removes waste from your blood. If the filter gets clogged (kidney damage), waste products (BUN and creatinine) build up in your blood. Monitoring these waste levels tells you how well the filter (kidneys) is working.

Regularly assessing BUN and creatinine levels can help prevent severe nephrotoxicity and ensure the patient's safety during gentamicin treatment.

• Monitor BUN and creatinine levels before starting therapy and periodically during treatment.
• Assess the patient's urine output and note any changes, as decreased urine output can indicate renal impairment.
• Ensure adequate hydration to help maintain renal function.
• Be aware of any other nephrotoxic drugs the patient might be taking to avoid additive effects.
• Report any significant increases in BUN or creatinine levels to the healthcare provider promptly for potential dose adjustment or discontinuation of gentamicin.

✘Incorrect answer options:

Hemoglobin levels and hematocrit measurements. Hemoglobin and hematocrit are important for assessing anemia and overall blood health but are not directly related to monitoring gentamicin therapy. Gentamicin does not typically affect these values.

Platelet counts and clotting times. Platelet counts and clotting times are crucial for assessing bleeding and clotting disorders, but gentamicin does not commonly affect these parameters. Monitoring these values is more relevant for patients on anticoagulants or those with clotting disorders.

Sodium and potassium levels. Sodium and potassium levels are important for monitoring electrolyte balance, but gentamicin does not typically cause significant disturbances in these electrolytes. Monitoring electrolytes is more relevant for patients on diuretics or those with conditions affecting fluid and electrolyte balance.

EXPLANATION

✔Correct answer:

This is a common response to lithium therapy; the patient should be monitored for suicidal tendencies. Lithium is a mood stabilizer commonly used to treat bipolar disorder. When patients first begin lithium therapy, there may be a period of adjustment where they experience depressive symptoms. It is essential to monitor these patients closely for any signs of suicidal tendencies, as this adjustment period can sometimes exacerbate underlying depression or precipitate suicidal thoughts.

Lithium works by affecting neurotransmitter activity in the brain, particularly serotonin and norepinephrine. The therapeutic effects of lithium often take several weeks to become fully apparent. During this initial period, patients may still experience mood fluctuations, including depressive episodes.

Starting lithium therapy can be compared to starting a new workout routine. Initially, your body might feel more tired and sore because it is adjusting to the new regimen. Similarly, the brain may experience mood fluctuations while adjusting to the effects of lithium.

It is crucial to provide support and close monitoring during this period to ensure the patient’s safety and well-being.

• Monitor the patient for signs of worsening depression and suicidal ideation.
• Provide a safe environment and remove any potential means of self-harm.
• Encourage open communication about their feelings and provide reassurance that mood stabilization can take time.
• Coordinate with the healthcare team to evaluate the patient's response to the medication and adjust the treatment plan as needed.
• Educate the patient and family members about the expected course of treatment and the importance of reporting any concerning symptoms immediately.

✘Incorrect answer options:

The treatment plan is ineffective; the patient needs a higher dose of lithium. Increasing the dose of lithium without proper evaluation can lead to toxicity. The therapeutic range of lithium is narrow, and it requires careful monitoring of serum levels to avoid adverse effects.

This is a typical reaction to lithium therapy; the patient should continue the current treatment plan. While depressive symptoms can occur, it is not advisable to simply continue the treatment without closer monitoring. Suicidal tendencies can develop during this period, and careful assessment and support are needed.

The treatment plan is ineffective; the patient needs an antidepressant. Introducing an antidepressant immediately might not be the best approach without thorough evaluation. Antidepressants can sometimes trigger manic episodes in patients with bipolar disorder. The primary approach should be monitoring and assessing the patient before making significant changes to the treatment plan.

EXPLANATION

✔Correct answer:

She is in shock and disbelief over her husband's death. The immediate response to a sudden and traumatic death often involves a state of shock and disbelief. This initial reaction is a common defense mechanism that helps the individual to temporarily distance themselves from the overwhelming emotions associated with the loss. By comforting others, the wife may be focusing on their needs as a way to cope with her own initial shock and disbelief.

According to Elisabeth Kübler-Ross's model, the first stage of grief is denial, where the individual is in shock and has difficulty accepting the reality of the loss. This stage is characterized by numbness and disbelief, serving as an emotional buffer to help the person gradually come to terms with the situation.

Think of the initial reaction to a sudden loss like a car's airbag deploying during a crash. It provides immediate protection and cushioning to prevent further injury. Similarly, shock and disbelief cushion the emotional impact of the loss, giving the person time to gradually adjust to the reality.

Nurses should provide a supportive presence and monitor the grieving individual's emotional state. It is important to acknowledge their emotions and offer resources for further support.

• Offer a quiet space for the wife to sit and process the news if needed.
• Encourage her to express her feelings and provide a listening ear.
• Inform her about available counseling services and support groups.
• Reassure her that experiencing shock and disbelief is a normal part of the grieving process.
• Observe for any signs of prolonged or complicated grief that might require professional intervention.

✘Incorrect answer options:

She has already progressed through the stages of grief. It is unlikely that the wife has already progressed through all the stages of grief immediately after the death. Grieving is a complex and individual process that typically unfolds over time, rather than in an instant.

She is suppressing anger related to her husband's death. While suppression of emotions, including anger, can occur, the immediate reaction is more commonly shock and disbelief. Anger is usually a later stage in the grief process, as described by Kübler-Ross.

She is showing acceptance and resolution of her husband's death. Acceptance and resolution are typically seen in the later stages of grief, after the individual has had time to process and come to terms with the loss. It is unlikely for someone to reach this stage so soon after a sudden and traumatic death.

EXPLANATION

✔Correct answer:

Face the patient and speak slowly with a slightly lower pitch. When communicating with individuals who have moderate hearing loss, it is important to consider both the volume and the frequency of speech. Speaking slowly helps ensure that each word is articulated clearly, which can aid in comprehension. Lowering the pitch of your voice is beneficial because high-pitched sounds are often harder for people with hearing loss to hear and understand. Facing the patient allows them to use visual cues, such as lip-reading and facial expressions, which can also assist in communication.

Hearing loss in elderly patients is often due to presbycusis, an age-related condition that affects the ability to hear higher frequencies. This condition results from changes in the inner ear, including the degeneration of hair cells and alterations in the auditory nerve.

Think of a hearing aid as a pair of glasses for your ears. Just as glasses help you see clearly by focusing light, facing the patient and speaking clearly helps focus the sound and visual cues, making it easier for the patient to "see" your words with their ears.

Nurses should educate family members on effective communication strategies that enhance understanding and ensure the patient's comfort.

• Encourage family members to gain the patient’s attention before speaking, possibly by gently touching their arm or saying their name.
• Instruct them to maintain eye contact and use natural facial expressions and gestures to support communication.
• Advise them to reduce background noise when having conversations to minimize distractions and enhance hearing clarity.
• Recommend using short, simple sentences and allowing extra time for the patient to process and respond to the conversation.
• Ensure family members understand the importance of patience and reassurance during communication.

✘Incorrect answer options:

Speak louder until the patient can hear you. While increasing volume might seem helpful, shouting can distort speech sounds and can be perceived as aggressive or frustrating by the patient. Louder speech may also not address the frequency loss experienced by many elderly patients.

Face the patient and speak rapidly in a high-pitched voice. Speaking rapidly can make it difficult for the patient to follow the conversation. High-pitched voices are often more difficult for those with hearing loss to understand, as high-frequency sounds are typically the first to be affected in presbycusis.

Use facial expressions and speak in your normal manner. While using facial expressions is beneficial, speaking in a normal manner may not be sufficient if it does not include the adjustments in pitch and speed necessary for the patient to understand better. Slightly lowering the pitch and speaking more slowly can significantly improve comprehension.

EXPLANATION

✔Correct answer:

The nurse should confirm that the consent form has been signed by the patient and is included in her chart. Nurse Carla's primary responsibility is to ensure that the consent form for the examination and evidence collection is signed by the patient and properly documented in her chart. This step is critical in protecting the patient's legal rights and ensuring that the examination is conducted with informed consent. Proper documentation of the signed consent form is also essential for maintaining the integrity of the legal process and the chain of evidence in cases of sexual assault.

Nurses are responsible for verifying that the patient fully understands the procedure and has agreed to it voluntarily. This helps in ensuring that the patient's autonomy and legal rights are respected, which is especially important in sensitive and potentially traumatic situations like sexual assault examinations.

Imagine you are about to participate in a research study. Before starting, the researcher (nurse) must make sure you have read and signed a consent form. This signed form (documented consent) is then kept on record to confirm that you agreed to participate with full knowledge of what is involved.

Nurse Carla should ensure the patient feels supported and informed throughout the consent process. This involves:

• Providing a private and comfortable space for the patient to read and sign the consent form.
• Clearly explaining the purpose of the examination and the procedures involved in a sensitive and compassionate manner.
• Confirming that the patient understands she has the right to refuse any part of the examination at any time.
• Ensuring the signed consent form is accurately documented and included in the patient's chart.
• Offering continuous emotional support and connecting the patient with counseling and other resources as needed.

✘Incorrect answer options:

The nurse should explain the examination procedure and obtain the patient's signature on the consent form. While it is important to explain the procedure and obtain the patient's signature, Nurse Carla's primary responsibility also includes verifying and documenting that the signed consent form is attached to the patient's chart. Simply obtaining the signature without proper documentation does not fulfill the full requirement.

The nurse should inform the physician that the patient has consented to the examination. Verbal confirmation to the physician is not sufficient. The consent must be documented in writing and included in the patient's medical records to ensure legal and ethical standards are met.

The nurse should ensure that either the patient or a family member has signed the consent form. In cases involving adult patients and sensitive issues like sexual assault, the patient herself must give consent. Family member consent is not appropriate unless the patient is incapacitated and unable to provide consent.

EXPLANATION

✔Correct answer:

Take responsibility for his actions and decisions. One of the key objectives in therapy, especially in the context of treating adolescent depression, is to help the adolescent develop a sense of personal responsibility. Encouraging the adolescent to take responsibility for his actions and decisions is crucial for fostering self-efficacy and autonomy. This approach empowers the adolescent to engage actively in his treatment, make healthier choices, and build resilience.

Cognitive-behavioral therapy (CBT) and other therapeutic approaches often emphasize personal responsibility as a way to help individuals understand the connection between their thoughts, behaviors, and emotional well-being. This principle is particularly important in adolescents, who are at a developmental stage where establishing a sense of independence and self-identity is critical.

Imagine teaching someone to ride a bike. While initial support and guidance are important, the ultimate goal is for them to pedal and steer on their own. Similarly, therapy aims to support the adolescent initially, but ultimately, he must learn to navigate his own life by taking responsibility for his actions and decisions.

Nurse Amy should facilitate discussions that encourage the adolescent to reflect on his choices, understand the impact of his actions, and develop problem-solving skills.

• Encourage open communication within the family to support the adolescent’s sense of responsibility.
• Use therapeutic techniques to help the adolescent identify and challenge negative thought patterns.
• Provide tools and strategies for the adolescent to manage stress and make informed decisions.
• Involve the family in setting realistic goals and supporting the adolescent’s efforts to achieve them.
• Reinforce positive behaviors and acknowledge the adolescent's progress in taking responsibility for his actions.

✘Incorrect answer options:

Trust the nurse to resolve his issues. While building trust with the nurse is important, the goal is not for the adolescent to rely on the nurse to solve his problems but to empower him to address his own issues.

Learn to manage anxiety and stress. Although learning to manage anxiety and stress is a valuable skill and an important part of therapy, it is not the primary objective in the context of this family meeting aimed at addressing responsibility.

Rely on the therapeutic community members for problem-solving. While support from the therapeutic community is beneficial, the objective is to encourage the adolescent to develop personal responsibility rather than dependence on others for problem-solving.

EXPLANATION

✔Correct answer:

"Time the interval from the start of one contraction to the start of the next one." To determine the frequency of uterine contractions, Maria should be taught to time the interval from the start of one contraction to the start of the next contraction. This measurement reflects how often the contractions are occurring, which is crucial for monitoring labor progression. The frequency of contractions provides information about the rhythmic pattern and whether labor is advancing appropriately.

In labor management, accurately assessing contraction frequency helps healthcare providers determine the stage of labor and decide on appropriate interventions. Frequent and regular contractions typically indicate active labor.

Imagine timing the intervals between waves crashing on the shore. To understand how often the waves come in, you would measure the time from the start of one wave hitting the shore to the start of the next wave. Similarly, to gauge contraction frequency, measure from the start of one contraction to the start of the next.

Nurse Laura should ensure Maria understands how to time her contractions accurately and provide a demonstration if necessary.

• Explain the importance of tracking contraction frequency for monitoring labor progression.
• Provide a step-by-step demonstration on how to measure from the start of one contraction to the start of the next.
• Give Maria a notepad or a contraction timing app to help her keep track of her contractions easily.
• Encourage Maria to note any patterns or changes in the frequency of contractions and to report these to her healthcare provider.
• Reassure Maria that it's normal for contraction patterns to vary early in labor and to contact her healthcare provider if she has any concerns or questions.

✘Incorrect answer options:

"Count the number of contractions in a 10-minute period." While this method might provide some information about contraction patterns, it does not give a precise measure of the frequency and is less commonly used in standard practice.

"Measure the length of each contraction from start to finish." This describes the duration of a contraction, not the frequency. Duration is important but is a different parameter used to assess labor progress.

"Record the time from the end of one contraction to the start of the next." This would measure the rest period between contractions, not the frequency. Understanding both frequency and rest period is important, but for determining frequency, the start-to-start interval is the correct approach.

EXPLANATION

✔Correct answer:

Asymmetry of the gluteal and thigh folds. One of the key signs of congenital hip dislocation (also known as developmental dysplasia of the hip) in infants is the asymmetry of the gluteal and thigh folds. When the infant is lying supine with the hips and knees flexed, the nurse can observe the skin folds on the inner thighs and buttocks. If there is a dislocation or subluxation of the hip, these folds will appear uneven or asymmetrical. This asymmetry is due to the improper positioning of the femoral head within the acetabulum, leading to differences in muscle and tissue distribution.

Congenital hip dislocation is a condition where the head of the femur is not properly seated in the hip socket. Early detection is crucial for effective treatment, which often involves the use of a harness or brace to ensure proper hip development.

Imagine looking at the seams on a pair of pants. If one leg is pulled higher than the other, the seams won't line up properly. Similarly, in congenital hip dislocation, the gluteal and thigh folds won't align evenly due to the displacement of the hip.

Nurse Jenny should perform a thorough assessment to confirm the suspicion and follow up with appropriate diagnostic measures and referrals.

• Perform the Barlow and Ortolani maneuvers to check for hip instability and confirm the diagnosis of hip dysplasia or dislocation.
• Document the findings, including the presence of asymmetry in the gluteal and thigh folds, and any positive signs from the maneuvers.
• Refer the infant to a pediatric orthopedic specialist for further evaluation and management.
• Educate the parents about the condition, the importance of early intervention, and what to expect in terms of treatment options and outcomes.

✘Incorrect answer options:

Lengthening of the limb on the affected side. In congenital hip dislocation, the limb on the affected side is often shortened rather than lengthened due to the dislocation of the femoral head.

Deformities of the foot and ankle. These are not typical signs of congenital hip dislocation. Foot and ankle deformities might indicate other conditions such as clubfoot, but they are not directly related to hip dysplasia.

Plantar flexion of the foot. This is not associated with congenital hip dislocation. Plantar flexion refers to the movement of the foot downward and is not a symptom of hip dislocation.

EXPLANATION

✔Correct answer:

Inform the caregiver that the baby will need medication. The presence of white, curd-like patches on the baby's oral mucous membranes is indicative of oral thrush, a fungal infection caused by Candida albicans. This condition is common in newborns and typically requires antifungal medication for treatment. Nurse Emily should inform Maria that the baby will need medication, such as an antifungal oral suspension, to treat the infection.

Oral thrush in infants can cause discomfort and feeding difficulties if not treated promptly. Early identification and appropriate treatment are crucial to prevent further complications and ensure the baby can feed comfortably.

Imagine a garden that has developed a patch of unwanted weeds. Just as you need a specific herbicide to effectively remove the weeds and prevent them from spreading, the baby needs antifungal medication to eliminate the thrush infection and stop it from causing further discomfort and feeding issues.

Nurse Emily should provide clear instructions to Maria on how to administer the medication and offer additional support and education on preventing future occurrences.

• Explain the signs and symptoms of oral thrush to ensure Maria understands the condition.
• Instruct Maria on the correct administration of the prescribed antifungal medication.
• Advise on proper bottle-feeding hygiene practices to prevent reinfection, such as sterilizing bottles and nipples after each use.
• Discuss general infant oral care and the importance of keeping the baby’s mouth clean.
• Provide information on follow-up care and when to seek further medical advice if symptoms persist or worsen.

✘Incorrect answer options:

Check the baby's blood glucose level. This action is not directly related to the presence of white patches in the baby's mouth. Blood glucose levels would be checked if there were concerns about hypoglycemia or diabetes, not for diagnosing or treating oral thrush.

Recommend changing the baby's formula. Changing the formula is unlikely to address the fungal infection causing oral thrush. The issue at hand is a fungal infection, not a problem with the baby's formula.

Advise the caregiver to avoid letting the baby sleep with the bottle. While this is good general advice to prevent dental caries and ear infections, it does not address the current issue of oral thrush. The immediate need is to treat the fungal infection with medication.

EXPLANATION

✔Correct answer:

A 60-year-old woman who reports having a sore throat. Influenza vaccination should generally be postponed in individuals who are experiencing moderate to severe acute illness with or without fever. A sore throat could be a symptom of an underlying illness that might warrant delaying the vaccination to avoid complicating the condition or confounding the diagnosis. Administering the vaccine during an acute illness can potentially mask symptoms or exacerbate the current condition.

According to the Centers for Disease Control and Prevention (CDC), individuals with moderate or severe illness should wait until they have recovered before receiving the flu vaccine. This precaution helps to avoid attributing any new symptoms or progression of illness to the vaccine, ensuring accurate diagnosis and treatment of the existing illness.

Think of the body like a construction site. If there's already a significant project underway (like dealing with an acute illness), it might not be the best time to start another project (like introducing a vaccine). Waiting until the current project is under control ensures that resources (the immune system) are available to handle the new task effectively.

Nurse Samantha should assess the severity of the woman's sore throat and any accompanying symptoms to determine if vaccination should be deferred.

• Perform a thorough assessment to determine the severity of the sore throat and any other symptoms.
• Consult with a healthcare provider if there is any uncertainty about whether to proceed with vaccination.
• Educate the patient about the rationale for potentially delaying the vaccine and arrange for follow-up to administer the vaccine once she has recovered.
• Document the assessment findings and the decision-making process regarding the vaccination.

✘Incorrect answer options:

A 45-year-old man with a shellfish allergy. A shellfish allergy is not a contraindication for the influenza vaccine. The concern with allergies typically relates to egg protein, which is used in the production of some influenza vaccines, but alternative egg-free vaccines are available.

A 66-year-old woman residing in a group home. Individuals in group homes are at higher risk for influenza and should be vaccinated unless there are specific contraindications. There is no indication here that the woman has an acute illness or other contraindications.

A 70-year-old woman with congestive heart failure. Chronic medical conditions like congestive heart failure actually increase the importance of receiving the influenza vaccine due to the higher risk of complications from the flu. As long as she is not currently experiencing an acute illness, vaccination is recommended.

EXPLANATION

✔Correct answer:

Below the umbilicus, on the mother's right side. The right occipital anterior (ROA) position indicates that the fetus's occiput (the back of the head) is oriented towards the mother's right anterior (front) side. In this position, the fetal heart tones are most likely to be heard below the umbilicus on the mother's right side because this is where the fetal chest is positioned closest to the maternal abdomen.

During prenatal checkups, determining the fetal position helps guide where to auscultate the fetal heart tones. For fetuses in an occipital anterior position, heart tones are typically heard below the umbilicus. The side of the mother's abdomen where the fetal back is located will generally be the optimal location for auscultation.

Imagine you have a radio and you want to hear it clearly. If the speaker of the radio is facing a particular direction, you will get the best sound quality by positioning yourself in line with the speaker. Similarly, to hear the fetal heart tones, you need to position the stethoscope where the fetal chest is closest to the mother's abdominal wall.

Nurse Kelly should use the following steps to ensure accurate auscultation of fetal heart tones:

• Place the patient in a comfortable position, typically semi-reclined.
• Use a Doppler or fetoscope to locate the fetal heart tones below the umbilicus on the mother's right side.
• Move the device slightly within the area to ensure the strongest and clearest sound of the fetal heartbeat.
• Document the fetal heart rate and any notable characteristics.
• Reassure the patient about the findings and answer any questions she may have.

✘Incorrect answer options:

Below the umbilicus, on the mother's left side. This location would be appropriate if the fetus were in a left occipital anterior (LOA) position, but not for ROA.

Above the umbilicus, on the mother's left side. This area is not typically used for auscultation of fetal heart tones in an ROA position. This would be more relevant for a breech presentation where the fetal heart tones are generally auscultated above the umbilicus.

Above the umbilicus, on the mother's right side. Similar to the left side, this location is not appropriate for auscultation of fetal heart tones in an ROA position. It may be relevant for a transverse or breech presentation but not for a cephalic presentation where the fetus's head is down.

EXPLANATION

✔Correct answer:

A 72-year-old patient with diabetes needing a dressing change for a stasis ulcer. An LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse) is well-suited to manage the care of a patient requiring dressing changes for a stasis ulcer. LPNs/LVNs are trained and competent in performing wound care, monitoring for signs of infection, and providing education on wound management. This task is within their scope of practice and allows them to use their clinical skills effectively while ensuring the patient's condition is managed appropriately.

According to the National Council of State Boards of Nursing (NCSBN) delegation guidelines, tasks assigned to LPNs/LVNs should be within their educational preparation and licensure. Dressing changes for a stasis ulcer are routine tasks that LPNs/LVNs handle, and this patient does not require the more complex assessment and decision-making skills that are within the RN's scope of practice.

Think of the healthcare team like a sports team where each player has specific roles. The LPN/LVN is like the midfielder in soccer, skilled at managing the flow of the game and performing crucial tasks like passing the ball. Assigning the LPN/LVN to wound care is like giving the midfielder a task they are trained for and excel at, ensuring the team functions smoothly.

Nurse Taylor should ensure that the LPN/LVN has all the necessary supplies and understands the specific wound care protocol for the patient.

• Provide clear instructions on the frequency and type of dressing change required.
• Review the patient's medical history to ensure there are no contraindications or special considerations.
• Ensure the LPN/LVN knows how to monitor for signs of infection and other complications.
• Offer support and be available for any questions or assistance the LPN/LVN might need during the procedure.

✘Incorrect answer options:

A 42-year-old patient with bone cancer who is complaining of pain. Managing complex pain in a cancer patient often requires thorough assessment and the administration of potent medications, which are best handled by an RN. This situation may also involve adjustments to pain management plans, requiring the RN's advanced assessment and decision-making skills.

A 55-year-old patient with terminal cancer being transferred to hospice home care. This scenario involves comprehensive discharge planning, education, and coordination with hospice services, tasks that require the RN's expertise in assessment, planning, and teaching.

A 23-year-old patient with a fractured right leg asking to use the urinal. Assisting with basic needs like using a urinal is within the scope of practice for a nursing assistant. This task does not require the clinical skills of an LPN/LVN and can be effectively managed by a nursing assistant.

EXPLANATION

✔Correct answer:

Side-lying position. After a tonsillectomy, placing Timmy in a side-lying position is the best choice to ensure his safety and comfort. This position helps facilitate drainage of oral secretions, blood, or vomit, reducing the risk of aspiration and ensuring an open airway. It also minimizes pressure on the surgical site and can help reduce postoperative swelling and pain.

Ensuring a clear airway is a primary concern in the immediate postoperative period, especially following surgeries in the oropharyngeal area. The side-lying position supports these goals by allowing gravity to assist in keeping the airway clear of fluids that might otherwise obstruct breathing or lead to aspiration pneumonia.

Imagine you're holding a cup of water after swirling it around, creating bubbles and foam. If you hold the cup upright, the bubbles and foam stay on top, and there's a risk of spilling. But if you tilt the cup slightly to the side, the bubbles and foam gently flow out without causing a mess. Similarly, placing Timmy in a side-lying position allows any blood, secretions, or vomit to drain out of his mouth safely, reducing the risk of choking and ensuring he can breathe easily.

Nurse Amber should monitor Timmy closely for signs of respiratory distress or excessive bleeding and ensure the side-lying position is maintained correctly.

• Regularly check Timmy's airway patency and breathing pattern.
• Observe for any signs of bleeding, such as frequent swallowing or coughing.
• Ensure that Timmy remains in the side-lying position until he is fully awake and can safely swallow and manage his secretions.
• Reassure and comfort Timmy, as the side-lying position might feel unfamiliar initially.
• Educate Timmy's caregivers about the importance of maintaining this position postoperatively to ensure a safe recovery.

✘Incorrect answer options:

Sims' position. Although similar to the side-lying position, Sims' position involves the patient being on their side with one leg bent and the other straight, which is less stable for a drowsy child and may not provide the same level of airway protection and drainage facilitation.

Supine position. Lying flat on the back is not recommended immediately after tonsillectomy because it increases the risk of aspiration of blood or secretions, potentially leading to airway obstruction and respiratory distress.

Prone position. Lying face down is not suitable as it can cause difficulty in breathing and is uncomfortable for a child recovering from throat surgery. It also does not facilitate proper drainage and could increase pressure on the surgical site.

EXPLANATION

✔Correct answer:

Gloves, gown, mask, and goggles. When performing a procedure such as inserting a nasogastric (NG) tube, Nurse Alex must protect themselves and the patient from potential infection and exposure to bodily fluids. The appropriate protective equipment includes gloves, a gown, a mask, and goggles.

• Gloves: Essential for preventing the transmission of pathogens through hand contact.
• Gown: Protects clothing and skin from contamination.
• Mask: Protects the mucous membranes of the mouth and nose from splashes or sprays of bodily fluids.
• Goggles: Protect the eyes from potential splashes of bodily fluids during the procedure.

These items together provide comprehensive protection against infection and ensure safety during the procedure.

This practice aligns with the Centers for Disease Control and Prevention (CDC) guidelines for standard precautions and personal protective equipment (PPE) use in healthcare settings. The goal is to reduce the risk of healthcare-associated infections (HAIs) and ensure the safety of both the healthcare provider and the patient.

Think of the PPE as armor for a knight. Just as a knight wears armor to protect against various threats, healthcare providers wear PPE to shield themselves from potential hazards like infections and bodily fluids during medical procedures.

Nurse Alex should follow proper donning and doffing techniques for PPE to maintain a sterile environment and prevent self-contamination.

• Educate on the correct order of putting on and removing PPE to minimize contamination risk.
• Ensure PPE fits properly to provide maximum protection.
• Demonstrate hand hygiene before and after donning and doffing PPE.
• Provide instructions on disposing of used PPE in appropriate biohazard containers.

✘Incorrect answer options:

Gloves, gown, goggles, and surgical cap. While this option includes many of the necessary items, a surgical cap is not typically required for NG tube insertion, and it omits the mask, which is crucial for protecting against splashes to the nose and mouth.

Sterile gloves, mask, plastic bags, and gown. Sterile gloves are not necessary for NG tube insertion; clean gloves are sufficient. Plastic bags are not appropriate PPE for this procedure. The option also omits goggles, which are important for eye protection.

Double gloves, goggles, mask, and surgical cap. Double gloves are generally not required for this procedure, and a surgical cap is unnecessary. This option also omits the gown, which is essential for protecting the body and clothing from contamination.

EXPLANATION

✔Correct answer:

Secure all medications in a locked cabinet. The most effective way to prevent accidental poisoning in toddlers is to ensure that all medications are securely stored in a locked cabinet. Toddlers are naturally curious and may climb or find ways to reach high places, so merely placing medications on a high shelf is not sufficient. Even childproof caps are not entirely foolproof, as some children may still manage to open them. Storing medications in various containers can lead to confusion and increases the risk of accidental ingestion. A locked cabinet provides a secure and reliable method to keep medications out of reach and sight of children.

According to the American Academy of Pediatrics (AAP), the best practice for preventing accidental poisoning is to store all hazardous substances, including medications, in a locked cabinet or out of reach and sight of children. This practice aligns with the principles of environmental safety and injury prevention in pediatric care.

Think of medications as precious jewels. Just as you would keep valuable jewelry locked away in a safe to prevent theft, you should keep medications locked away to prevent accidental poisoning by curious toddlers.

Nurse Emily should instruct the mothers on the importance of consistently using locked cabinets for medication storage and checking that the lock mechanisms are functioning properly.

• Educate the mothers on the types of locks available and how to install them on cabinets.
• Advise on regular checks to ensure the locks remain secure and are not easily broken.
• Emphasize the importance of keeping the key to the locked cabinet in a safe but accessible place for adults.
• Discuss the risks associated with improper medication storage and the potential consequences of accidental poisoning.
• Provide information on emergency procedures and who to contact in case of suspected poisoning.

✘Incorrect answer options:

Ensure all medication bottles have childproof caps. While childproof caps are an important safety feature, they are not completely reliable. Some children may still be able to open them, and reliance solely on these caps may provide a false sense of security.

Keep medications on the highest shelf in a cupboard. Toddlers are known for their climbing abilities and may still manage to reach high shelves. This method is not as secure as using a locked cabinet, as it does not eliminate the risk of access.

Store medications in various containers. This practice can lead to confusion and improper identification of medications, increasing the risk of accidental ingestion. It also does not address the issue of keeping medications out of reach of children.

EXPLANATION

✔Correct answer:

In a private room to protect her from infections by other patients and health care staff. Thrombocytopenia is a condition characterized by a low platelet count, which increases the risk of bleeding. When this condition results from acute lymphocytic leukemia (ALL), the patient's immune system is often compromised, either due to the leukemia itself or the treatments (such as chemotherapy). This immunocompromised state makes Mrs. Thompson more susceptible to infections. Placing her in a private room minimizes her exposure to potential infectious agents carried by other patients, visitors, or healthcare staff, thus protecting her fragile immune system.

Acute lymphocytic leukemia affects the bone marrow and blood, resulting in a reduced ability to produce healthy blood cells, including white blood cells (WBCs) crucial for fighting infections. Thrombocytopenia exacerbates this condition by reducing the body's ability to form blood clots, increasing the risk of bleeding. Therefore, protecting the patient from infection is paramount, as any infection could lead to severe complications due to her compromised immune system.

Imagine Mrs. Thompson as a delicate flower in a garden. To keep her safe and healthy, she needs to be placed in a protective greenhouse away from pests and harsh weather conditions. Similarly, a private room acts as a "greenhouse," shielding her from potential infections.

Nurses should prioritize infection control measures, including strict hand hygiene, the use of personal protective equipment (PPE), and minimizing the number of visitors.

• Educate the patient and family about the importance of infection prevention and isolation protocols.
• Monitor the patient's vital signs and laboratory results regularly to detect early signs of infection or bleeding.
• Administer prescribed medications, such as antibiotics or antifungals, as a prophylactic measure.
• Ensure the room is kept clean and sanitized to reduce the risk of environmental contamination.
• Encourage limited, safe social interaction through virtual means to address the patient’s emotional needs while maintaining isolation precautions.

✘Incorrect answer options:

In a private room to prevent her from infecting other patients and health care staff. This choice is incorrect because Mrs. Thompson’s condition does not pose an infection risk to others. Thrombocytopenia and acute lymphocytic leukemia do not cause her to be infectious; rather, they make her more susceptible to infections.

In a shared room to provide her with social interaction during her hospital stay. While social interaction is important for psychological well-being, placing her in a shared room increases the risk of infection. The priority for a patient with thrombocytopenia and a compromised immune system is to minimize infection risk, which outweighs the benefit of social interaction in this context.

In a shared room to give her the chance to talk about her illness. Similar to option C, although discussing her illness might offer emotional support, the risk of infection from other patients or visitors in a shared room is too high. The focus should be on protecting her from potential infections, which can be life-threatening given her condition.