A client is brought to the emergency department after falling from of a ladder and is showing signs of confusion and disorientation. The spouse states the client appeared to have lost consciousness. The nurse is provided with a list of current medications and healthcare power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Currently prescribed medications.

Falling from a ladder as reason for admission.

Increasing confusion of the client.

Client's healthcare power of attorney.

Answer and Explanation

The Correct Answer is C

A. Currently prescribed medications are important information, but in this emergent situation, the nurse should first report on the client's condition and immediate concerns.

B. Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.

C. Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.

D. The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential head
trauma.

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Correct Answer is C

Explanation

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. This is not accurate; BRCA1 and BRCA2 genes are involved in DNA repair, and mutations in these genes increase cancer risk.
B. The choice of treatment is best determined by the sensitivity of these genetic markers. While genetic markers can influence treatment decisions, this option does not directly address the role of BRCA1 and BRCA2 mutations in cancer risk.
C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. This is correct. Mutations in these genes significantly increase the risk of developing breast and ovarian cancer.
D. The prognosis of breast cancer is most successful when these markers are inherited mutations.
This statement is incorrect. The presence of BRCA1 or BRCA2 mutations influences risk, not necessarily prognosis or treatment success.

A. Provide counseling that most contraceptives protect against infection. B. Remain non-judgmental and assure the client of confidentiality. C. Inform the client that complications will not result from reinfection. D. Clarify that all STIs are transmitted through sexual intercourse.

Correct Answer is B

Explanation

A. Providing counseling about contraceptives may not address the immediate concern of managing genital herpes or the risks associated with multiple sexual partners.
B. Remaining non-judgmental and assuring the client of confidentiality is crucial to establishing trust and ensuring open communication. This approach encourages the client to share accurate information about their sexual history and current concerns, which is essential for effective STI management and prevention.
C. Informing the client that complications will not result from reinfection is inaccurate and may minimize the seriousness of the STI. Genital herpes can cause recurrent outbreaks and potentially lead to complications such as neonatal herpes if transmitted to a newborn during childbirth.

D. Clarifying that all STIs are transmitted through sexual intercourse is true but does not address the client's specific situation or provide guidance on managing genital herpes and reducing the risk of transmission.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

Correct Answer is C

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide?

Correct Answer is B

Explanation

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Which action should the school nurse implement to provide secondary prevention for school- aged children?

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?