A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?
Use a cushion when sitting.
Perform range of motion exercises.
Document abdominal girth.
Weigh every morning.
The Correct Answer is D
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale for A: Elevated energy level is a common effect of cocaine use, but it does not encompass the full range of behaviors associated with the drug's effects.
Rationale for B: Powerful cravings for more cocaine can develop over time, especially after the initial effects wear off, but they are not the immediate behavior observed.
Rationale for C: High self-esteem may be a temporary effect, but it does not specifically indicate current behavior associated with cocaine use.
Rationale for D: Euphoria is one of the primary effects of cocaine and is typically experienced shortly after use. This intense feeling of pleasure is a hallmark behavior observed in clients who have recently used cocaine.
Correct Answer is A
Explanation
A) Correct - Flaring of the nares is a sign of increased respiratory effort and can indicate acute respiratory distress.
B) Incorrect - While a resting respiratory rate of 35 breaths/min is elevated for a 4-month-old infant, it may not necessarily indicate acute distress, especially when considered along with other signs.
C) Incorrect - Bilateral bronchial breath sounds may indicate lung pathology, but they are not specific to acute respiratory distress.
D) Incorrect - Diaphragmatic respirations, where the abdomen moves more than the chest during breathing, are normal for infants. They do not necessarily indicate acute respiratory distress.
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