NCLEX-PN

electrolytes like sodium, potassium, and chloride, and the accompanying fever exacerbates fluid loss through increased sweating and respiratory rate. The other options, including the 67-year-old recovering from hepatic injury, the 84-year-old admitted with a hip fracture, and the 16-year-old with Type I diabetes, present different clinical scenarios where electrolyte imbalances are not the primary concern or are not as acutely prominent. (See Identifying Signs and Symptoms of Fluid and Electrolyte Imbalances ) 30.​Which of the following is a nursing diagnosis that reflects some unexpected responses to therapy ? A.​ Episiotomy extension related to a forceps delivery B.​ Respiratory depression related to NSAIDs C.​ Hemothorax related to a latex allergy D.​ All of the above Correct Response: A Explanation: The correct answer is (A) Episiotomy extension related to a forceps delivery. This nursing diagnosis signifies unexpected responses to therapy, specifically in the context of maternal trauma, lacerations, damage to the pelvic floor, bleeding, and the unintended extension of an episiotomy to the anus during a forceps delivery. These unexpected outcomes emphasize the need for nursing intervention and specialized care. The incorrect responses include (B) , where respiratory depression related to NSAIDs is an inaccurate association, as respiratory depression is more commonly linked with narcotic analgesics like morphine. (C) , involving hemothorax related to a latex allergy, is also incorrect as hemothorax is not a typical response to a latex allergy but is more commonly associated with complications from invasive procedures. (D) , claiming all of the above as nursing diagnoses reflecting unexpected responses to therapy, is inaccurate as only option A truly aligns with unexpected outcomes in the context of forceps delivery. Understanding the specific associations between nursing diagnoses and therapeutic responses is vital for effective client care and intervention. (See Evaluating Clients for Unforeseen Adverse Reactions to Treatment ) 31. An LPN is talking with a client scheduled to undergo a vasectomy in the next few minutes. He states, “I know I signed the form and all, but I’m not feeling so sure of this. It can be reversed pretty easily, right?” What is the LPN’s best response? A.​ “It’s normal to feel a little nervous before a procedure like this one.” B.​ “Yes, vasectomies can be reversed, but I’m sure once you have it you won’t regret it.” C.​ “It sounds like you might be a little nervous. Don’t worry, this is a pretty minor procedure, and the doctor doing it is the best we have. You’re in great hands.” D.​ “It sounds like you have a few more questions you’d like answered. Let me grab the doctor quickly so he can answer them for you.” Correct Response: D Explanation: The correct answer is (D) "It sounds like you have a few more questions you’d like answered. Let me grab the doctor quickly so he can answer them for you." This response is the most appropriate as it demonstrates the LPN's sensitivity to the client's uncertainties about the vasectomy,

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