A weight gain of 1 lb (approximately 0.45 kg) per day is excessive and unrealistic for lean body mass accretion. Such rapid weight gain is a significant indicator of fluid retention and potential fluid overload, which can strain the cardiovascular system. A safe and appropriate weight gain goal for a client on nutritional support is typically 0.5 to 2 lbs (0.23 to 0.9 kg) per week. This statement demonstrates a fundamental misunderstanding of the therapeutic goals and potential complications of enteral nutrition, indicating a clear need for further teaching by the nurse.

A. Reporting diarrhea that persists for more than 2-3 days is the correct action, as it can signify a significant complication requiring medical intervention to prevent dehydration and electrolyte imbalance.

C. Elevating the head of the bed to at least 30-45 degrees during and after feedings is a critical aspiration precaution that uses gravity to prevent reflux and aspiration pneumonia.

D. Opened enteral formula is a growth medium for bacteria; it should be refrigerated and discarded after 24 hours to prevent contamination and subsequent gastrointestinal infection.

1. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier.

Regarding Correct Answer (B): Chapter 45, Nutrition, discusses monitoring patient outcomes. It emphasizes that weight gain should be gradual. A rapid daily gain suggests fluid retention, a complication to be reported (p. 1135, "Monitoring for Complications").

Regarding Incorrect Option (C): Chapter 45, Nutrition, explicitly states, "A major cause of complications is aspiration of formula into the tracheobronchial tree... To prevent aspiration, allow the head of the bed to be elevated to a minimum of 30 degrees, preferably 45 degrees" (p. 1133, "Aspiration of Formula").

Regarding Incorrect Option (D): Chapter 45, Nutrition, details safe administration practices, including that the "hang time" for formula in an open system at room temperature is typically 8 hours, and any unused, opened formula must be refrigerated and discarded after 24 hours (p. 1132, Box 45.11 "Procedural Guidelines: Administering Enteral Tube Feedings").

2. Bankhead, R., Boullata, J., Brantley, S., et al. (2009). Enteral nutrition practice recommendations. Journal of Parenteral and Enteral Nutrition, 33(2), 122-167. https://doi.org/10.1177/0148607108330314

Regarding Incorrect Option (A): Section 7, "Monitoring the Patient Receiving EN," recommends monitoring for gastrointestinal tolerance, including diarrhea. It notes that if diarrhea is severe or persistent, the cause should be investigated and managed (p. 147).

Regarding Incorrect Option (C): Section 6, "Administration," recommends, "To decrease the risk of aspiration, elevate the head of the bed (HOB) to 30°-45°" (p. 144).

Projection is an ego defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or motives to another person. In this scenario, the client has romantic and sexual feelings for her physician. To cope with these potentially unacceptable or overwhelming feelings, she unconsciously projects them onto the doctor, believing that he is the one in love with her. This distortion of reality protects her from acknowledging her own desires. This specific manifestation is also characteristic of an erotomanic delusion, which can be a symptom in clients with schizophrenia.

A. Displacement: This involves shifting feelings from an original, threatening source to a less threatening substitute. The client's feelings are still directed at the physician, not a different target.

C. Reaction formation: This is the process of behaving in a way that is the exact opposite of one's true, unacceptable feelings. The client is not acting opposite to her feelings.

D. Suppression: This is the conscious, intentional act of pushing unpleasant thoughts or feelings out of one's mind. The client's belief is a delusion, an unconscious process, not a conscious choice.

1. Townsend, M. C., & Morgan, K. I. (2018). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (7th ed.). F.A. Davis Company. In the chapter on "Mental Health and Mental Illness," projection is defined as "attributing feelings or impulses unacceptable to one’s self to another person" (Table 2-2, Ego Defense Mechanisms, p. 20).

2. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (11th ed.). Wolters Kluwer. Chapter 4, Section 4.5, "Defense Mechanisms," describes projection as a defense in which what is emotionally unacceptable in the self is unconsciously rejected and attributed to others.

3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). The clinical picture described aligns with an erotomanic type delusion, defined as the delusion that another person is in love with the individual. This delusion often involves projection of the individual's own feelings (p. 90). https://doi.org/10.1176/appi.books.9780890425596

The nursing process is a systematic, five-step clinical decision-making framework: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Assessment is the foundational first step, which involves the systematic collection, organization, validation, and documentation of patient data (subjective and objective). This comprehensive data provides the basis for the second step, Diagnosis, where the nurse analyzes the assessment findings to identify patient problems and formulate a nursing diagnosis. Without a thorough assessment, an accurate and appropriate nursing diagnosis cannot be made.

A. Write goals and objectives: This is a component of the Planning phase, which occurs after a nursing diagnosis has been identified.

C. Plan interventions: This is also part of the Planning phase, which is based on the established nursing diagnosis and goals.

D. Perform evaluation: This is the final step of the nursing process, conducted after interventions have been implemented to assess goal achievement.

1. Toney-Butler, T. J., & Thayer, J. M. (2023). Nursing Process. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/. (See section: "Phases of the Nursing Process," Paragraph 1, which lists assessment as the first phase).

2. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of Nursing (10th ed.). Elsevier. Chapter 17, "Nursing Diagnosis," states, "The diagnostic process flows from the assessment process and includes decision-making steps" (p. 232).

3. National Council of State Boards of Nursing (NCSBN). (2022). 2023 NCLEX-RN® Test Plan. The framework of the nursing process (Assessment, Analysis/Diagnosis, Planning, Implementation, Evaluation) is integrated throughout the test plan as a fundamental concept for providing safe and effective nursing care. (See Section III, "Clinical Judgment/Nursing Process," p. 5).

Waterhouse-Friderichsen syndrome is a rare, fulminant, and often fatal complication most commonly associated with severe meningococcemia (Neisseria meningitidis infection). The syndrome is defined by massive, bilateral adrenal hemorrhage, which leads to acute adrenal insufficiency. This abrupt loss of adrenal function, particularly cortisol and aldosterone production, results in profound hypotension, shock, and disseminated intravascular coagulation (DIC). The hallmark of this condition is a rapid progression to peripheral circulatory collapse. While other listed options are potential complications of bacterial meningitis, they describe different pathophysiological processes.

B. Syndrome of inappropriate antidiuretic hormone (SIADH) is a distinct complication of meningitis causing fluid retention and hyponatremia, not adrenal hemorrhage or primary circulatory collapse.

C. Cerebral edema and hydrocephalus are direct central nervous system complications from inflammation and obstructed cerebrospinal fluid flow, not the systemic adrenal failure seen in Waterhouse-Friderichsen syndrome.

D. Auditory nerve damage is a common neurological sequela of meningitis due to inflammation affecting cranial nerves, but it is unrelated to the adrenal crisis defining this syndrome.

1. Stephens, D. S. (2018). Meningococcal Meningitis. In J. L. Jameson, A. S. Fauci, D. L. Kasper, S. L. Hauser, D. L. Longo, & J. Loscalzo (Eds.), Harrison's Principles of Internal Medicine (20th ed.). McGraw-Hill Education. Chapter 151, section "Fulminant Meningococcemia (Waterhouse-Friderichsen Syndrome)."

2. Sonino, N., & Sonino, E. (2023). Waterhouse-Friderichsen Syndrome. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560593/. (See "Introduction" and "Pathophysiology" sections).

3. Varon, J., & Chen, K. (2008). The "sound" of a frightful syndrome. The Journal of Emergency Medicine, 35(2), 205–206. https://doi.org/10.1016/j.jemermed.2007.07.043 (See Abstract and Case Report sections describing the progression to shock).

4. Johns Hopkins Medicine. (n.d.). Waterhouse-Friderichsen Syndrome. Health Library. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/waterhousefriderichsen-syndrome. (See "What are the symptoms..." section, which lists shock as a primary symptom).

The classic clinical presentation of placenta previa is sudden, painless, bright red vaginal bleeding in the second or third trimester. Upon abdominal examination, the uterus is typically soft, relaxed, and non-tender. This is because the bleeding originates from the separation of the placenta from the lower uterine segment, and the blood escapes vaginally without irritating the uterine muscle (myometrium). The absence of uterine tenderness and rigidity is a key diagnostic feature that helps differentiate placenta previa from abruptio placentae.

A. A rigid, boardlike abdomen: This is the hallmark sign of a moderate to severe abruptio placentae, where concealed bleeding irritates the myometrium, causing tetanic contractions.

B. Uterine atony: This refers to the failure of the uterus to contract effectively after delivery and is a primary cause of postpartum hemorrhage, not an antepartum finding.

D. Hypertonicity of the uterus: This finding, characterized by excessive uterine tone and contractions that do not fully relax, is characteristic of abruptio placentae.

1. Oyelese, Y., & Smulian, J. C. (2006). Placenta Previa, Placenta Accreta, and Vasa Previa. Obstetrics & Gynecology, 107(4), 927–941. In the section "Clinical Presentation and Diagnosis," the article states, "The classic presentation of placenta previa is painless vaginal bleeding... The uterus is usually soft and nontender." (p. 929). https://doi.org/10.1097/01.AOG.0000207559.15715.98

2. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Spong, C. Y. (Eds.). (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education. In Chapter 41, "Obstetrical Hemorrhage," the text differentiates the clinical findings, noting that with placenta previa, "uterine palpation does not typically elicit tenderness."

3. University of California, San Francisco (UCSF) School of Medicine. (n.d.). Obstetrics and Gynecology Clerkship: Third Trimester Bleeding. Course materials describe the physical exam for placenta previa as revealing a "soft, non-tender uterus," contrasting it with the "firm, tender uterus (often with contractions)" seen in placental abruption.

Thalassemia is a genetic blood disorder causing chronic anemia. The primary treatment for severe forms is frequent blood transfusions. A major, life-threatening complication of chronic transfusion therapy is iron overload (hemosiderosis), as the body cannot naturally excrete the excess iron from transfused red blood cells. This iron accumulates in and damages vital organs like the heart, liver, and endocrine glands. Therefore, it is critical for the patient and family to be educated on the signs and symptoms of iron overload (e.g., fatigue, joint pain, arrhythmias, abdominal pain) to ensure early detection and adherence to chelation therapy, which removes excess iron from the body.

A. Iron supplementation is contraindicated because it would exacerbate the iron overload that already results from hemolysis and frequent blood transfusions.

B. While cardiac complications can occur from iron overload, routine weekly blood pressure monitoring is not a primary, specific discharge instruction for thalassemia.

D. Patients are encouraged to participate in physical activity as tolerated to promote well-being; a blanket restriction on exercise is inappropriate.

1. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's nursing care of infants and children (11th ed.). Elsevier. In Chapter 29, "The Child with Hematologic or Immunologic Dysfunction," the section on Thalassemia Major (Cooley Anemia) discusses the therapeutic management, stating, "A complication of the repeated transfusions is hemosiderosis... To prevent organ damage from iron overload, chelation therapy... is begun." This underscores the importance of managing and monitoring for iron overload.

2. National Heart, Lung, and Blood Institute (NHLBI). (2022, March 24). Thalassemia - Treatment. U.S. Department of Health & Human Services. In the section "Iron Chelation Therapy," it is stated, "Blood transfusions can lead to a buildup of iron in the blood (iron overload). This condition can damage the liver, heart, and other parts of the body... your doctor may prescribe iron chelation therapy to remove excess iron from your body." This highlights iron overload as a direct consequence of treatment requiring management and patient awareness.

3. Angelucci, E., & Barosi, G. (2013). Management of iron overload in thalassemia and other congenital anemias. In A. V. Hoffbrand & D. G. Higgs (Eds.), Postgraduate Haematology (7th ed., pp. 127-141). Wiley-Blackwell. Chapter 9 details the pathophysiology of transfusional iron overload and emphasizes patient education for adherence to chelation therapy as a cornerstone of management to prevent organ toxicity.

The therapeutic range for lithium is notoriously narrow, requiring close monitoring to maintain efficacy and prevent toxicity. For acute manic episodes, the target serum level is typically 1.0 to 1.5 mEq/L. For long-term maintenance therapy, the desired range is lower, generally between 0.6 and 1.2 mEq/L. The option 0.5–1.5 mEq/L correctly encompasses both the maintenance and acute therapeutic ranges. Levels below 0.5 mEq/L are generally subtherapeutic, while levels exceeding 1.5 mEq/L are associated with a significant increase in the risk of toxicity.

A. 0.25–1.0 mEq/L: The lower end of this range (0.25 mEq/L) is subtherapeutic and would likely be ineffective in managing bipolar disorder.

C. 1.0–2.0 mEq/L: Serum concentrations above 1.5 mEq/L are generally considered toxic. This range extends into dangerous levels that can cause serious adverse effects.

D. 2.0–2.5 mEq/L: This range represents severe lithium toxicity, which can lead to life-threatening complications such as seizures, coma, and cardiovascular collapse.

1. Hedya, S. A., & Avula, A. (2023). Lithium Toxicity. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499992/. (See "Pathophysiology" and "History and Physical" sections, which state therapeutic levels are 0.6 to 1.2 mEq/L, with toxicity beginning at 1.5 mEq/L).

2. University of Washington, Department of Psychiatry and Behavioral Sciences. (n.d.). AIMS Center Bipolar Disorder Medication Quick Reference Guide. Retrieved from https://aims.uw.edu/resource-library/bipolar-disorder-medication-quick-reference-guide/. (This guide specifies the therapeutic blood level for Lithium as 0.6-1.2 mEq/L).

3. Ghaemi, S. N. (2019). The evidence for and against the use of lithium in bipolar disorder. Acta Psychiatrica Scandinavica, 140(5), 394-396. https://doi.org/10.1111/acps.13096 (This article discusses standard therapeutic levels, noting the typical target range of 0.6-1.2 mmol/L, which is equivalent to mEq/L for lithium).

A pulse oximeter is a non-invasive device that measures the peripheral oxygen saturation of arterial blood (SpO2). It functions by emitting two wavelengths of light (red and infrared) through a translucent, pulsating vascular bed, such as a fingertip or earlobe. The device then measures the differential absorption of this light by oxygenated hemoglobin (oxyhemoglobin) and deoxygenated hemoglobin. By analyzing these differences in light absorption during arterial pulsations, the oximeter calculates the percentage of hemoglobin molecules that are saturated with oxygen, providing a continuous estimate of arterial oxygenation.

A. O2 content of the blood: This is incorrect because pulse oximetry does not measure the oxygen dissolved in plasma, only the saturation of available hemoglobin.

C. PO2: This is incorrect as it refers to the partial pressure of oxygen dissolved in the blood, a value measured directly through an arterial blood gas (ABG) analysis.

D. Affinity of hemoglobin for O2: This is incorrect as it describes the binding strength between oxygen and hemoglobin, which is influenced by factors like pH and temperature, not measured by oximetry.

1. Jubran, A. (2015). Pulse oximetry. Critical Care, 19(1), 272. In the "Principles of operation" section, paragraph 1, it states, "Pulse oximetry provides a noninvasive and continuous estimate of arterial oxygen saturation (SpO2)." https://doi.org/10.1186/s13054-015-0984-8

2. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier. In Chapter 30, "Oxygenation," under the section "Pulse Oximetry," it is specified that the device measures "the oxygen saturation of hemoglobin in arterial blood." (p. 579).

3. Johns Hopkins University. (n.d.). Arterial Blood Gas. Johns Hopkins Medicine, Health Library. This resource differentiates between measurements, stating, "A pulse oximeter only measures oxygen saturation... An ABG test measures oxygen saturation, but it also measures the partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2)." This clarifies why options B and C are distinct.

4. World Health Organization. (2011). Pulse oximetry training manual. WHO Press. In Module 1, "The Basics," Section 1.2, "What is pulse oximetry?", it is defined as "a non-invasive method used to measure the level of oxygen saturation in the blood." (p. 4).

The most immediate nursing intervention after a suspected rupture of membranes is to assess the fetal heart rate (FHR). This is the priority because of the risk of umbilical cord prolapse. When the membranes rupture, the umbilical cord can be washed down with the gush of fluid and become compressed between the fetal presenting part and the maternal pelvis. This compression obstructs blood flow and oxygen to the fetus, which is immediately reflected in the FHR as bradycardia or severe variable decelerations. Assessing the FHR is the fastest way to determine fetal well-being and identify this life-threatening emergency.

A. Noting the fluid is an important assessment but is secondary to evaluating fetal status. Fetal well-being is the highest priority.

C. The physician must be notified, but the nurse should first perform a critical assessment to provide accurate, up-to-date information, such as the FHR.

D. Confirming the rupture of membranes with a nitrazine test is appropriate but not the first priority. The immediate risk to the fetus must be assessed first.

1. Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2020). Maternity and Women's Health Care (12th ed.). Elsevier. In Chapter 16, "Labor and Birth Processes," under the section "Rupture of Membranes," the text states, "The first priority of care after the membranes rupture is to assess the FHR and pattern" (p. 381).

2. National Council of State Boards of Nursing (NCSBN). (2022). 2023 NCLEX-RN® Test Plan. This question aligns with the Client Needs Category "Reduction of Risk Potential," which requires the nurse to "identify acute, life-threatening complications" and "initiate immediate interventions." Assessing FHR post-ROM is a key intervention to mitigate the risk of fetal compromise (p. 21).

3. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2021). Fetal Heart Monitoring Principles and Practices (6th ed.). Kendall Hunt Publishing. Chapter 4 discusses the evaluation of fetal well-being and emphasizes that events like rupture of membranes are critical points for FHR assessment to detect potential cord compression events.

The client is exhibiting splitting, a primitive defense mechanism commonly associated with borderline personality disorder. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive whole. The client's statement, "Nobody in here seems to really care... I thought nurses cared about people!" demonstrates this "all-or-nothing" thinking. She is devaluing the current nursing staff as "all bad" because they are not meeting her idealized expectation of what nurses should be ("all good"). This dichotomous thinking is the hallmark of splitting.

A. Reaction formation: This is expressing the opposite of one's true feelings. The client is expressing anger and hostility, which appear congruent with her internal state.

B. Rationalization: This involves creating logical-sounding excuses to justify unacceptable feelings or behaviors. The client is not making an excuse for her actions.

D. Sublimation: This is the channeling of unacceptable impulses into socially acceptable actions. The client's verbal hostility is not a socially constructive outlet.

1. Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer. In Chapter 18, "Personality Disorders," the text describes splitting as a primary defense mechanism used by clients with borderline personality disorder, characterized by the tendency to view others as either all good or all bad (p. 341).

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). In the section on Borderline Personality Disorder (301.83), the diagnostic criteria include "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation," which is the behavioral manifestation of splitting (p. 663).

3. Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355–1381. This article discusses primitive defenses in BPD, defining splitting as "the segregation of contradictory experiences of the self and of significant others" (p. 1360). https://doi.org/10.1017/S095457940999009X