A client is admitted with abdominal pain, loss of appetite, and a weight loss of 25 lb (11 kg) in the last four months. During the admission assessment, the client describes to the nurse of having no interest in playing cards with friends anymore and feels worthless most days. Which nursing problem should the nurse address first?

"Risk for self-directed violence as evidenced by feelings of hopelessness."

"Chronic low self-esteem as evidenced by feelings of worthlessness."

"Anxiety as evidenced by abdominal discomfort secondary to depression."

"Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months."

Answer and Explanation

The Correct Answer is A

A. "Risk for self-directed violence as evidenced by feelings of hopelessness": The client’s feelings of hopelessness, combined with significant weight loss and loss of interest in activities, suggest possible depression. Hopelessness is a key symptom of depression, which can increase the risk for self-harm or suicide.

B. "Chronic low self-esteem as evidenced by feelings of worthlessness": Feelings of worthlessness are part of the larger picture of the client’s depression. The priority is to address the immediate risk of harm, which takes precedence over chronic low self-esteem.

C. "Anxiety as evidenced by abdominal discomfort secondary to depression": While abdominal discomfort can be a symptom of depression, it is secondary to the more immediate concern of the client’s potential risk for self-directed violence.

D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months": The significant weight loss is concerning, but it is likely a result of the client’s depression. The focus should first be on addressing the client’s safety, followed by nutrition and weight restoration.

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Correct Answer is C

Explanation

A. Perform active range of motion exercises: Active ROM exercises are beneficial for maintaining joint mobility and circulation, but they may not sufficiently reduce spasticity in clients with upper motor neuron lesions.

B. Apply compression stockings: Compression stockings help prevent venous thromboembolism and manage edema, but they do not treat muscle spasticity. They offer circulatory support, not neuromuscular control, and therefore would not alleviate the client’s current concern.

C. Give antispasmodic medications: Antispasmodics such as baclofen or tizanidine directly target muscle spasticity by acting on the central nervous system. These medications reduce the frequency and intensity of spasms, improving comfort and mobility in clients with spinal cord injuries.

D. Massage the extremities twice a week: Massage may offer relaxation and temporary relief but is not a primary treatment for spasticity. It does not alter the neurophysiological causes of muscle spasms and is unlikely to produce sustained control over involuntary muscle activity.

A. Tacos. B. Chocolate milkshake. C. Pizza. D. Sugar cookies.

Correct Answer is D

Explanation

A. Tacos: Tacos are often spicy and greasy, both of which can relax the lower esophageal sphincter and aggravate GERD symptoms in children by increasing acid reflux episodes.

B. Chocolate milkshake: Chocolate and high-fat dairy both reduce LES pressure and increase gastric acid secretion, worsening reflux. The milkshake also adds volume, which can trigger symptoms.

C. Pizza: Pizza is acidic (due to tomato sauce), high in fat, and often spicy—an unhealthy combination for a child with GERD. It’s one of the most commonly reported reflux-triggering foods.

D. Sugar cookies: Sugar cookies are bland, low in fat, and non-acidic, making them a safe snack choice for children managing GERD symptoms through dietary adjustments.

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Naxlex Comprehensive Predictor Exams

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Correct Answer is C

Explanation

Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions?

Correct Answer is D

Explanation

Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

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Exhibits Drag from Word Choices to complete the sentence. According to the lab values, the client has dropdownrelated to dropdownordropdown.

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The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply. Reference Range: White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]